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Review Article

Toothbrush A key to mechanical plaque control


Deepak Grover, Ranjan Malhotra, Sumati J. Kaushal, Gurpreet Kaur
Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India

ABSTRACT

Despite the wide range of methods available, mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for a majority of the population. Several different toothbrushing methods with manual brushes exist. The popularity of various techniques has waxed and waned over the twentieth century. However, no one method of brushing has been found superior to the other. However, plaque control by toothbrushing alone is not sufficient to control gingival and periodontal diseases because periodontal lesions are predominantly interdental. For years dental authorities have instructed their patients on how to brush their teeth correctly. However, many people lack the patience and do not follow dental instructions for more than a brief period. Therefore, studies were initiated in the belief that the introduction of power brushing would help the average person brush his teeth with greater efficiency. The purpose of this article is to update the available information on the toothbrush designs, tooth brushing methods, and the introduction of powered and ionic brushes.
Key words: Interdental contacts, plaque, toothbrush

Introduction
Dental plaque is established as the principle etiological agent of dental caries and periodontal disease. Recent investigations have stated that gingivitis may develop within two weeks without oral hygiene, and that early carious lesions may be detected after about four weeks, when the plaque is allowed to accumulate. Prevention of these two oral diseases in individuals is based, to a great extent, on the effective removal of plaque on a daily basis. Various authors have shown the effect of mouth cleaning in the healing and prevention of periodontal disease. Despite the wide range of methods available, mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for a majority of the population. When performed well, for an adequate duration of time, manual brushing is highly effective for most patients.

The Council of Dental Therapeutics has quoted, In fact, the data from some studies emphasize the ability of persons to maintain good oral hygiene through effective use of a conventional toothbrush if they possess reasonable dexterity and have been trained adequately in the proper use of the brush. Several different toothbrushing methods with manual brushes exist. The popularity of various techniques has waxed and waned over the twentieth century. However, no one method of brushing has been found superior to the other. Toothbrushing is a completely accepted part of daily life and good oral hygiene practice. However, plaque control by toothbrushing alone is not sufficient to control gingival and periodontal diseases because periodontal lesions are predominantly interdental. For years dental authorities have instructed their patients on how to brush their teeth correctly. However, many people lack the patience and do not follow dental instructions for more than a brief period.
Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 2012

Address for Correspondence: Dr. Deepak Grover, Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India. Email: preet342@yahoo.com Date of Submission: 10-05-2012 Date of Acceptence: ???

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Therefore, studies were initiated in the belief that the introduction of power brushing would help the average person brush his teeth with greater efficiency. Although earlier studies did not conclusively prove any differences in the efficiency of plaque removal between electric and manual toothbrushing, clinical trials over the last few years showed that in closely supervised trials electric toothbrushing appeared to be superior to manual brushing. The recent introduction of some ionic toothbrushes seems all set to revolutionize home care maintenance by all people, although perfection still remains an elusive goal. Plaque control is one of the key elements of the practice of dentistry. It permits each patient to assure responsibility for his or her own health on a daily basis. Without it, optimal health through periodontal treatment cannot be attained or preserved.

Kieser and Groeneveld [4] evaluated another novel toothbrush design (Snake brush) that was characterized by double angulations of handle and neck. In a 30day parallel design study this toothbrush showed significantly higher levels of plaque removal than two control brushes, with greatest reduction of plaque in the lingual areas.
Toothbrush head

The Manual Toothbrush


There are numerous manual toothbrush designs, and claims of superiority for plaque removal by individual brands have been made in the past. However, World Workshops on plaque control and oral hygiene practices have consistently concluded that there is insufficient evidence to prove that any one toothbrush design is superior to another (Frandson[1]). At the European Workshop on mechanical plaque control, it was agreed that the features of an ideal manual toothbrush should include: (Egelberg and Claffey[2]) 1. Handle size appropriate to use, for age and dexterity 2. Head size appropriate to the size of the patients mouth 3. Use of endrounded nylon or polyester filaments not larger than 0.009 inches in diameter 4. Use of soft bristle configuration, as defined by the acceptable International Industry Standards (ISO) 5. Bristle patterns, which enhance plaque removal in the approximate spaces and along the gum line.
Toothbrush handles

Barnarius et al. (1967) compared brush sizes (Long head 51 mm and short head 31 mm) on students and patients, with a brushing time of 0.5, 1, and 2 minutes, for efficacy and for possible influence of the toothpaste. Plaque removal was 39% after 0.5 minutes of brushing, with the test brushes; 40% after one minute, and 60% after two minutes. The results were similar whether or not toothpaste was used. The shortheaded toothbrush was significantly most effective. Wasserman [5] observed a statistically significant reduction in plaque accumulation after use of a deep grooved design toothbrush. In contrast, Thevissen et al.[6] found a conventional flat multitufted brush significantly more effective than a convexshaped brush. Two kinds of bristle materials are used in toothbrushes: Natural bristles from the hair of hog or wild boar. rtificial filaments made predominantly from A Nylon (0.006 to 0.4 mm). In case of interdental brush 0.075 mm. Nylon bristles vastly predominate in the market. In terms of homogeneity of materials, uniformity of bristle size, elasticity, resistance to fracture, and repulsion of water and debris, nylon filaments are clearly superior. This is because of their tubular form; natural bristles are more susceptible to fraying, breaking, contamination with diluted microbial debris, softening, and loss of elasticity. Rounded bristle ends cause fewer scratches on the gingiva than flat bristles with sharp ends. Bristles hardness is proportional to the square of the diameter and inversely proportional to the square of the bristles length. Diameters of commonly used bristles range from: 0.007 inch (0.2 mm) for soft brushes. 0.012 inch (0.3 mm) for medium brushes 0.014 inch (0.4 mm) for hard brushes. Soft bristle brushes of the type described by Bass have gained wide acceptance Bass (1948) recommended a straight handle and nylon bristles of 0.007 inch (0.2 mm) in diameter and 0.406 inch (10.3 mm) long, with rounded ends, arranged
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Toothbrush bristles

The preference of handle characteristics is a nature of individual taste. The handle should fit comfortably in the palm of the hand; it may be straight or angled, thick or thin. Brushes with modest angulations between the head and the handle are available. Kanchanakamol and Srisilapanan[3] evaluated a newly designed Concept 45 toothbrush for plaque removal in children and subsequently in adults. The handle was designed to facilitate the Bass toothbrushing technique and it was shown that this toothbrush could remove significantly more plaque than a conventional toothbrush with a standard handle.
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in three rows of tufts, six evenly spaced tufts per row with 80 to 86 bristles per tuft. For children, the brush is smaller with thinner (0.005 inch or 0.1 mm) diameter and shorter (0.344 inch or 8.7 mm) diameter bristles. The American Dental Association (ADA) has described the range of dimension of acceptable brushes; a brushing surface 1 to 1.25 inches (25.4 to 31.8 mm) long and 5/16 to 3/8 inch (7.9 to 9.5 mm) wide, two to four rows of bristles, and 5 to 12 tufts per row. A toothbrush should be able to reach and efficiently clean most anxious of the teeth.[7] In contrast, Pretaraspanedda et al.[8] demonstrated that significantly more plaque was removed after a single brushing when brushes with higher density were used. Beatty et al.[9] had conducted a comparative analysis of the plaque removal ability of 0.007 inch and 0.008 inch toothbrush bristles and demonstrated favorable results for the thinner bristles in school children.
Novel toothbrush designs

In this study, a Dentrust group removed a significant amount of tooth buccal and lingual plaque and the flatheaded toothbrush removed a significant amount of buccal plaque only. Dr. B.S. Jagadish Pai[13] conducted a study to evaluate the efficacy of the newtripleheaded toothbrush (Superbrush)TR and conventional (Plakoff) toothbrush. The ability of plaque reduction on the labial and lingual aspect was also compared. There was a statistically significant difference in plaque index on the lingual aspect (P < 0.02) between the baseline and one week. The result showed that the super brush was more effective in the lingual aspect than in the labial aspect.
Vshaped

The new generation manual toothbrushes that have been tested in recent years exhibit better plaque removal ability than do the older brushes. The differences are most significant when individuals have been instructed in the proper brushing technique.
Twoheaded (double headed)

Bastiaan[10] compared the plaque removing effect of a doubleheaded brush with that of a singleheaded flat toothbrush (Oral B 35) in 39 patients. The patients were instructed in the Bass technique and brushes were used for one week. The results indicated that lingually the doubleheaded brush was superior to the singleheaded brush, whereas, buccally no difference was found. Agerholm[11] tested the plaque removing efficacy of the new doubleheaded brush (Duodent 2000) in comparison with a conventional brush (Oral B 32). Twentyseven patients were attending the clinic for an initial course of hygiene treatment and 23 were recall patients with persistently inadequate plaque control. The doubleheaded toothbrush helped achieve significantly better lingual and palatal plaque control.
Tripleheaded

Bergenholtz et al. (1969, 1984[14]) compared a Vshaped and control multitufted toothbrush in a superior toothbrushing study and found significantly better interproximal plaque removal with the Vshaped brush. In 1984, same authors confirmed these differences in comparison to spaced and multitufted toothbrushes. Bergenholtz et al.[14] could not find a difference in the plaque removing ability of straight, multitufted, and Vshaped brushes when they were used unsupervised. When used professionally, the Vshaped toothbrush was better at proximal plaque removal than the straight one. Better interproximal access of Vshaped toothbrushes was observed by Yankell et al. [15]. These authors evaluated different toothbrushing methods with six different toothbrushes and observed that a hard toothbrush with three rows, 12 mm length, and filament of 0.33 diameter removed most of the plaque (72%).
Twolevel toothbrush

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The tripleheaded toothbrush is intended to clear the buccal, occlusal, and lingual or palatal surface of the teeth at one time. Yankell et al.,[12] conducted a study to test a new tripleheaded, toothbrush design (Dentrust) that claims to enable simultaneous plaque removal on the buccal, lingual, and occlusal surfaces. The brushes were compared with a standard flat toothbrush (OralB P35). In a laboratory test, the Dentrust toothbrush bristles were consistently superior to two manual toothbrushes in achieving proximal use.
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Guilfoyle in 1977 developed the Two bristle level angulated handled toothbrush (Reach). Finkelstein and Grossman[16] evaluated its effectiveness on the lingual and facial surfaces in adult subjects by measuring the stained plaque on each facial and lingual surface, in 5% increments. The angled, bileveled brush was significantly superior to the conventional, straighthandled, multitufted toothbrushes in plaque removal efficiency. In a fourweek crossover study on adult volunteers (aged 19 to 64 years) Wasserman (1985) compared a newly developed Deepgrooved twolevel toothbrush (Improve) with a conventional flat brush, with 48 tufts and four rows. Significantly less plaque was found lingually in the molar teeth (P < 0.001) and plaque was also reduced significantly (P < 0.03) on the buccal interproximal surfaces (P < 0.5) when the improve brush (DeepGrooved twolevel) was used.
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Curved: (collis curved brush)

The Collis curved brush, with two short middle rows and curved outer rows, was found by Shory et al.,[17] to be more effective on the interproximal and gingival, sulcular areas than a straight multitufted bristle brush. It also improved the gingival conditions and removed significantly more plaque than the regular toothbrush. Avery [18] confirmed these results and showed a significant, (P < 0.001) 50%, reduction of plaque in students using the Collies curved brush compared to a conventional brush. Williams and Schuman[19] found that handicapped children were able to remove more lingual plaque with a curved brush.
Circular and diamonds

contained in the handle of these toothbrushes tends to change the surface charges of the tooth by an influx of positively charged ions. The plaque with similar charges is then repelled and detached from the tooth surfaces and is in turn attracted by the negatively charged bristles of the toothbrush. More efficient plaque removal interproximally is claimed to be their main advantages.

Toothbrushing Methods
There are several specific toothbrushing techniques. The popularity of various techniques have waxed and waned over the twentieth century. The scrub technique is probably the oldest. It merely applies the name to the typical uninstructed action of brushers. The Charters and Stillman techniques for gingival message were popular in the 1930s and 1960s. Bass described what is probably the most popular method taught today and his theories were popularized in the 1970s. No one method of toothbrushing has been found to be superior to others. The best method is the one that suits the individuals needs and abilities, and the responsibility of the dentist is to instruct the patient on how to perform the task thoroughly. Most toothbrushing methods can be classified into one of the eight groups based on the motion and position of the brush. a. Sulcular: Bass b. Roll: Rolling stroke, modified Stillman c. Vibratory: Stillman, Charters, Bass d. Circular: Fones e. Vertical: Leonard f. Horizontal g. Physiological: Smith h. Scrubbrush method

A circular toothbrush found a significant improvement in plaque removal compared to a conventional toothbrush. It was also found that the Oral B brush, with a flat surface was significantly more effective. A major shortcoming of brushes has been the Blocking effect of tight and dense brittle tufts, which prevents individual tufts from entering the interproximal areas.
Light energy conversion and Ionic manual toothbrush

Two recent studies introduced another novel approach in manual toothbrushing. Hoover et al.[20] investigated the plaque removing potential of a new light energy conversion toothbrush incorporated with a semiconductor of titanium dioxide (TiO2). A similar toothbrush without a semiconductor served as the control. After a period of three weeks the new toothbrush showed significantly more reduction of plaque on the buccal surfaces in a group of 73 school children. The authors speculated, As the buccal surfaces are more likely to allow light to reach the semiconductors during brushing than the lingual areas, it is possible that the reported photocatalytic property of the semiconductor may be involved in the observed radiation of the plaque. Van Swol et al. [21] evaluated the effect of a small, imperceptible electric current on the established dental plaque and gingivitis during manual toothbrushing in 64 adults over a period of six months. The result showed significantly more improvement from the baseline to six months of the test over the unchanged control brush. Hukeeba dental, Japan, has recently introduced a new generation of hyG ionic toothbrushes that are based on the principle that plaque is positively charged and thus attach to the negatively charged tooth surfaces. The lithium battery
Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 2012

Powered Toothbrush
Mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for a majority of the population. When performed well for an adequate duration of time, manual brushing is highly effective. However, for most patients neither of these criteria is fulfilled. One possible way to overcome their limitations associated with manual brushing is to develop a mechanical brushing device. As early as 1855, the Swedish watchmaker Frederick Wilhelm Tornberg patented a mechanical toothbrush. The first electric toothbrush came much later and was first introduced in the 1960s. They provided a brush head capable of a variety of motions driven by a power source. The first electric brushes mimicked the backandforth motion, commonly used with a manual toothbrush, when first introduced. There were many reports of the effectiveness of such devices. However, an early
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authoritative report reviewed such research and stated that both manual and electric toothbrushes were equally effective in removing plaque (Ash 1983). Due to lack of clear superiority and many problems of mechanical breakdown, powered toothbrushes fell out of favor and during the mid 1960s they gradually disappeared from the market. At the World Workshop in Periodontics 1966, the consensus was that in nondentally oriented persons and persons not highly motivated to oral healthcare, as well as those who had difficulty in mastering a suitable hand brushing technique, the use of an electric brush with its standard movement might result in more frequent and better cleansing of the teeth (Greene 1966, WWP). Since then, research and development have continued and many modifications have been made to the electric toothbrush design[22].

the efficacy of cleaning and reducing the likelihood of toothbrush abrasion and gingival trauma in the long term (Heasman[22]).
Ideal characteristics of a powered toothbrush: (Heasman[22])

An active brush tip to facilitate plaque control around posterior teeth and at interdental sites An orthodontic head for brushing around and beneath the components of fixed orthodontic appliances Rotating/spiraling filaments for interproximal cleaning An audible clicking mechanism to warm the brusher when a preset brushing force has been searched Timers
Brush movement

Design and Mode of Action


Generally, the brush heads of powered toothbrushes tend to be more compact than those of conventional, manual brushes. The bundles of bristles are arranged either in rows or in a circular pattern mounted on a round head. The bristles are also arranged as more compact single tufts, which facilitate interproximal cleaning and brushing in less accessible areas of the mouth. The traditional designs of the head, operate with a conventional sidetoside, arcuate, or backandforth motions, whereas, circular brush heads have oscillating, rotational, or counterrotational movements.
Types of motion

Oscillation of the brush head is powered by a battery pack in the handle of the brush. This may be a simple electric motor driving an eccentric cam as a series of gears for rotary action. Another method of generation is by magnetostriction, which is similar to that employed by ultrasonic scalers and results in a higher mode of oscillation. Their frequency of oscillation varies from 40 Hz (cycle/second) for batterypowered brushes to 250 Hz for magnetostrictive devices.
Biophysical action

Reciprocating more back and forth in a line Arcuate filament ends follow an arc as they move up and down Orbital circular Vibratory Elliptical oval Dual motion more than one of the previous motions mentioned
Speed

Speed varies from low to high among the different models. The number of strokes/minute varies from 1000 cycles/minute for a replaceable battery type to about 3600 oscillations/minute for an arcuate model. The rechargeable battery types operate at approximately 2000 complete strokes/minute. A number of new generation powered toothbrushes, also incorporate design features that are aimed at improving
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Electric toothbrushes may have a potentially improved action due to rapid vibration of the buccal head in a liquid medium. This may result in both cavitations and acoustic microstreaming. Cavitational activity encompasses a wide variety of bubble behaviors, ranging from the relatively gentle linear pulsation of gasfilled bodies (Stable cavitation) to the violent and highly destructive formation and collapse of vaporfilled voids and cavities (Transient cavitation). Electric toothbrushes operate at relatively low frequencies and are unlikely to generate the destructive transient form of cavitation. Acoustic microstreaming will occur around the bristles of an electric toothbrush. This streaming is accompanied by large hydrodynamic shear stresses, even though the actual streaming velocities that produce them are relatively low. These shear forces may dislodge the plaque, but they are not strong enough to disrupt the biological cells or tissues that require hydrodynamic shear stresses of the order of 1 103 Nm2. Such forces will occur readily at ultra sonic frequencies of 25 Hz. Often if an antiplaque agent (irrigant) is incorporated into the liquid, then a synergistic effect may be used (i.e., the mechanical and chemical effects work
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together). This is used around endodontic files, where the associated irrigant is sodium hypochlorite. Such effects could prove useful with the electric toothbrush, if the associated toothpaste has an antiplaque agent incorporated within it.
Indications for the use of powered toothbrushes

Braun OralB plaque control (D5, D7, and D9)

There is considerable evidence that powered toothbrushes are beneficial in achieving improved plaque control in specific patient groups. Patients with fixed orthodontic appliances Those for whom there is also evidence that powered toothbr ushes are more effective in reducing decalcifications Children and adolescents Handicapped and severely retarded children Institutionalized patients, including the elderly, who are dependent on others Interestingly, however, powered toothbrushes have been shown to be of no significant benefit for patients with Rheumatoid arthritis, for children who are wellmotivated brushers, and for patients with chronic adult periodontitis. Clearly, however, from the industrial point, a Special group alone does not constitute a sufficiently wide market and powered toothbrushes are now recommended on a communitywide basis, with a view to enhance an interest in oral hygiene practices.
Efficacy studies

This electric brush was first launched in 1991, and had a small circular brush head, which made an oscillating/rotating movement. In 1996, the frequency of the Braun OralB electric toothbrush was increased from 47 Hz to 63 Hz (Model D9). In addition, the angle of rotation was decreased from 70 to 60. A new toothbrush introduced in 1993, had a rectangular brush head with bristles arranged in a saw tooth design. The sidetoside movement of the sonicare was operated at a high frequency of 260 Hz. WuYuan et al.[23] tested sonicare and found that 60% of the plaque on a titanium surface could be disrupted at a distance of 2 mm away from the object. In a study by Johnson and McInnes[24], in adults, plaque removal with sonicare was compared with a manual brush OralB 30. After four weeks of use, sonicare was found to be up to 11 times more effective than the manual brush in removing lingual and interproximal plaque. In two other studies (McInnes et al. 1993, 1994[25]), it was seen that sonicare damaged the adherence properties of the oral bacteria, Actinomyces viscosus, by destroying the fimbriae of the organization. The safety of this brush was demonstrated by Donly KJ[26] who concluded that Sonicare had no potential for destruction of restoration, but was effective in stain removal.
Ultrasonic toothbrush Sonicare (sonic toothbrush)

The main electric toothbrushes, which are compared in the literature, are the Braun Oral Bplaque removers (D5, D7, and D9) Interplak, Rotadent, Sonicare, and sonex. These electric toothbrushes have been studied in relation to their ability to remove plaque and improve the gingival condition in comparison with either manual toothbrushes or electric toothbrushes from different manufactures.
Rotadent

This electric brush was the first clinically investigated powered brush, which turned away from the conventional design of electric toothbrushes. It had a rotary action and was a singletuft brush, with small bristles that reached one surface per tooth. It came with three brush head designs (Shortpointed, elongated, and hollowcup brush tip).
Interplak

When a prototype of an ultrasonic brush was compared with a manual brush by Goldman[27], patients were not aware of any ultrasonic effect, but the ultrasonic brush produced slightly improved plaque removal. Terezhalmy et al.[28] compared the ultrasonic toothbrush to the oralB 40 toothbrush in 54 subjects, during a 30day trial. The ultrasonic toothbrush was significantly more potential in plaque removal. Zimmer S,[29] evaluated the efficacy of the Ultra Sonex Ultima (R) in comparison with a conventional manual toothbrush in 64 healthy volunteers. The Turesky modification of the QuigleyHein plaque index (PI), the approximal plaque index (API), and the PBI were recorded at baseline. Four and 8 weeks after baseline, the indices were recorded again. The authors concluded that the Ultra Sonex Ultima may be more efficacious than manual toothbrushes in removing plaque and preventing gingivitis in patients without severe periodontal disease.

This electric toothbrush was the next innovative toothbrush design and was introduced into the market in the mid 1980s. The interplak toothbrush had a rectangular brush with six to eight bristle tufts, which individually counter rotated.
Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 2012

References
1. Frandsen A. Mechanical oral hygiene practices: Stateofthe science review. In: Loe H, Kleinman DV, editors. Dental plaque control measures and oral hygiene practices. Oxford: IRL Press; 1986. p.93-116.
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Grover, et al.: Kindly provide running tittle??? Egelberg J, Claffey N. In: Proceedings of the European Workshop on Mechanical Plaque Control. Quintessence Books; 1998. p.169-72. Kanchanakamol U,Srisilapanan P. The effectiveness of the newly designed Concept 45 degrees toothbrush for removal of dental plaque in primary schoolchildren. Int Dent J 1992;42:78-82. Kieser J,Groeneveld H. Aclinical evaluation of a novel toothbrush design. JClin Periodontol1997;24:419-23. Wasserman BH. A new deepgrooved design toothbrush. A clinical evaluation. Clin Prev Dent1985;7:7-11. Thevissen E,Quirynen M,van Steenberghe D. Plaque removing effect of a convexshaped brush compared with a conventional flat brush. JPeriodontol1987;58:861-7. Carranzas Clinical Periodontology9thEdition. Pretaraspanneda P, Grossman E, Curro FA, Generallo C, et al. Toothbrush bristle density: Relationship to plaque removal. Am J Dent 1989;2:345-8. Beatty ???, etal. Acomparative analysis of the plaque removal ability of. 007 and. 008 toothbrush bristles. Clin Prev Dent 1990;12:22-7. Bastiaan RJ. Acomparison of the clinical effectiveness of a single and doubleheaded toothbrush. JClin Periodontol 1984;11:331-9. Agerholm DM. A clinical trial to evaluate plaque removal with a doubleheaded toothbrush. Br Dent J1991;170:411-3. Yankell SL, Emling RC, Perez B. Asixmonth clinical evaluation of the Dentrust toothbrush. JClin Dent1996;7:106-9. Pai BS, etal. Comparative evaluation plaque removing capacity of a new triple headed tooth brush and a conventional brush. JISP 2003;6:???. Bergenholtz A, Gustafsson LB, Segerlund N, Hagberg C, Ostby N. Role of brushing technique and toothbrush design in plaque removal. Scand J Dent Res 1984;92:344-51. Yankell SL, Green PA, Greco PM, Stoller NH, Miller MF. Test procedures and scoring criteria to evaluate toothbrush effectiveness. Clin Prev Dent 1984;6:3-8. Finkelstein P, Yost KG, Grossman E. Mechanical devices versus antimicrobial rinses in plaque and gingivitis reduction. Clin Prev Dent 1990;12:8-11. ShoryNL. Astudy of the effectiveness of two types of toothbrushes for 18. 19. 20. 21. removal of oral accumulations.J Am Dent Assoc 1987;115:717-20. Avery KD. Give your teeth a hug: Asimplilied brushing technique for children. JDent Child 1984;51:371-3. Williams NJ, Schuman NJ. The curvedbristle toothbrush: An aid for the handicapped population. JDent Child 1988;55:291-3. Hoover JN, Singer DL, Pahwa P, Komiyama K.Clinical evaluation of a light energy conversion toothbrush.J Clin Periodontol 1992;19:434-6. Van Swol RL, Van Scotter DE, Pucher JJ, Dentino AR. Clinical evaluation of an ionic toothbrush in the removal of established plaque and reduction of gingivitis. Quintessence Int 1996;27:389-94. Heasman PA, McCracken GI. Powered toothbrushes: A review of clinical trials. JClin Periodontol 1999;26:407-20. WuYuan CD, et al. Ability of the Sonicare Electronic Toothbrush to Generate Dynamic Fluid Activity that Removes Bacteria. JClin Dent 1994;5:89-93. Johnson B, McInnes C. Clinical evaluation of the efficacy and safety of a new sonic toothbrush. JPeriodont 1994;65:692-7. McInnes C, Johnson B, Emling RC, Yankell SL. Clinical and computerassisted evaluations of stain removal ability of the Sonicare electronic toothbrush. JClin Dent 1994;5:13-8. Donly KJ, Vargas M, Meckes M, Sharma A, Kugel G, Hurley E. Invitro comparison of restoration wear and tensile strength following extended brushing with sonicare and a manual toothbrush. JCIin Dent 1997;8:30-5. Goldman HM. Effectiveness of an ultrasonic toothbrush in a group of uninstructed subjects. JPeriodontol 1974;45:84-7. Terezhalmy GT, Iffland H, Jelepis C, Waskowski J. Clinical evaluation of the effect of an ultrasonic toothbrush on plaque, gingivitis and gingival bleeding: A six month study. JProsthet Dent 1995;73:97-103. Zimmer S, Nezhat V, Bizhang M, Seemann R, Barthel C. Clinical efficacy of a new sonic/ultrasonic toothbrush. JClin Periodontol2002;29:496-500.

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How to cite this article: ???. Source of Support: Nil, Conflict of Interest: None declared

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Author Queries??? AQ1: AQ2: AQ3: AQ4: AQ5: AQ6: Kindly provide Running Title. Kindly check Affiliation. Kindly provide reference details Kindly provide reference citation for author Bergenholtz, 1969 Kindly provide reference details for author McInnes et al. 1993. Few References cross cited and few References have not present. kindly check and provide all Reference cross citations.

AQ7: AQ8: AQ9: AQ10: AQ11

Kindly provide year and complete detials. Kindly provide author first name and also provide rest of authors. Kidnly confirm author Pai BS name and also provide rest of author name and provide page number. Kindly confirm highlighted author and provide rest of author name. Kindly provide date of Acceptance.

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1 2 3 4 5 6 7 8 9 10 11 AQ10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56

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Indian Journal of Oral Sciences Vol. 3 Issue 2 May-Aug 2012