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1. RODUCTION

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Introduction
Microbial dental plaque biofilm continually forms on the tooth surfaces and is
the primary agent in the development of dental caries and periodontal diseases.
If plaque biofilm is completely removed with self‐care procedures, dental caries
and periodontal diseases can be prevented. Unfortunately, the majority of the
population is unable, uninstructed, or unwilling to spend the time to adequately
remove plaque from all tooth surfaces. Plaque deposits can be removed either
mechanically or chemically. The focus of this chapter is the mechanical removal
of plaque by using toothbrushes and toothbrushing techniques.
History Of Toothbrushes
The exact origin of mechanical devices for cleaning teeth is unknown.
However, since ancient times, individuals have chewed twigs from plants with
high aromatic properties. Chewing these twigs freshened breath and spread out
fibers at the tips of the twig, which were then used for cleaning the teeth.
Toothbrushing twigs actually date back to 3500– 3000 b.c. when the
Babylonians and the Egyptians made these brushes by fraying the end of a twig.
Tombs of the ancient Egyptians containing toothsticks alongside their owners
have been found. In Arabic countries, individuals used a piece of the root of the
arak tree because the root fibers stood out like bristles; this device was called a
siwak. These chew sticks not only helped to physically clean teeth but also
helped to prevent plaque development because the fibers contained antibacterial
oils and tannins.1
To this day, the siwak and other chew twigs are used
throughout the world to remove plaque. During the Tang dynasty ( 618– 907
a.d.), the Chinese invented a toothbrush with a handle and bristles. They used
hog bristles similar to those in some contemporary brushes. The premise exists
that the Chinese version of the toothbrush spread to Europe when travelers
brought it back from China.2

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Manual toothbrushes designs
Manual toothbrushes vary in size, shape, texture, and design A manual
toothbrush consists of a head with bristles and a handle. When the bristles are
bunched together, they form tufts. The head is arbitrarily divided into the toe,
which is at the extreme end of the head, and the heel, which is closest to the
handle(Figure1).3,4
The shank is a constriction that
usually occurs between the handle and the head.
The handle is the area held by the hand during
brushing. Toothbrushes are manufactured in
different sizes large, medium, and small to adapt
better to the oral anatomy of different individuals.
Toothbrushes Profiles
Toothbrushes also differ in their defined hardness or texture and are classified
as hard, medium, soft, or extra soft. Extra soft and soft toothbrush bristles are
preferred because hard bristles damage teeth by causing abrasion of the tooth
surface. More recently, toothbrush heads have been altered to vary bristle
lengths and placement in attempts to better reach interproximal areas
( Figures 2 and 3 ). Handles have also been ergonomically designed to
accommodate multiple dexterity levels to work efficiently and safely without
causing stress to hand muscles or damage to the gingiva.3
Figure 3 Cross‐sectional profile of five toothbrushes.
Figure 2 Overhead appearance of selected toothbrushes.
Figure 1 Parts of a toothbrush.

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Nylon Versus Natural Bristles
(Nathe, 2014) (Nathe, 2014) (Nathe, 2014)The nylon bristle is superior to the
natural hog bristle in several aspects. Nylon bristles flex as many as 10 times
more often than natural bristles before breaking; they do not split or abrade and
are easier to clean. The shape and stiffness of nylon bristles can be standardized.
Natural bristle diameters vary greatly in each filament.This can lead to wide
variations in the resulting texture.
Manual Toothbrushing Methods The purposes of toothbrushing include
(1) removal of plaque biofilm and disturbance of plaque re‐formation, (2)
removal of food, debris, and stain from the oral cavity, (3) stimulation of the
gingival tissues, and (4) application of a toothpaste containing specific
ingredients to prevent demineralization of tooth structure, periodontal diseases,
and tooth sensitivity or to attain remineralization.5,6

5. 4
1. Bass Method
The Bass method is acceptable for all patients, specifically for those with
periodontal involvement. This method is effective at removing plaque at the
gingival margin and directly below it. The toothbrush bristles are angled
apically at a 45‐ degree angle to the long axis of the tooth. The filaments are
then gently placed subgingivally into the sulcus. With very light pressure, the
brush is vibrated with very short horizontal strokes while keeping the bristles in
the sulcus. After several vibrations, the bristles are removed from the sulcus,
and the brush is repositioned on the next two or three teeth ( Figure 4 ).
2. Rolling Method
The rolling technique is most appropriate for children whose dexterity is not
sufficient to master the Bass technique. The bristles are positioned apically
along the long axis of the tooth. The edge of the brush head should be touching
the facial or lingual aspect of the tooth. Then with light pressure, the bristles are
rolled against the tooth from the apical position toward the occlusal plane. This
motion is repeated several times; then the brush is repositioned on the next teeth
with bristles overlaping a portion of the teeth previously cleaned. The heel or
toe of the brush is used on the lingual aspect of the anterior teeth ( Figure 5 ).
3. Stillman Method
The Stillman method was originated to massage and stimulate the gingiva while
cleansing the cervical areas. The bristles are positioned apically along the long axis
of the tooth. The edge of the brush head should be touching the facial or lingual
aspect of the tooth. A slight blanching effect should be seen; then the brush is
slightly rotated at a 45‐degree angle and vibrated over the crown ( Figure 6 ).
4. Charters Technique
The Charters technique is effective for cleaning around devices used to correct
improper contact of opposing teeth (orthodontic appliances) and plaque under
abutment teeth of a fixed bridge. The bristles are placed at a 45‐degree angle

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toward the occlusal or incisal surface of the tooth. The bristles should touch at
the junction of the free gingival margin and tooth. A circular vibratory motion is
then activated (Figure 7 ).
5. Fones Method
The Fones method is not to be used by adults but can be an easy technique for
young children to learn. The teeth are clenched, and the brush is placed inside
the cheeks. The brush is moved in a circular motion over both maxillary and
manibular teeth. In the anterior region, the teeth are placed in an edge‐to‐edge
posi- tion and the circular motion is continued. On the lingual aspect, an in‐and
out stroke is used against all surfaces. This technique can be damaging if done
too vigorously ( Figure 8 ).
6. Leonard Technique
In the Leonard technique, the toothbrush is placed at a 90‐degree angle to the
long axis of the tooth. The teeth are held in an edge‐to‐edge position. Next the
toothbrush is moved in a vertical, vigorous motion up and down the teeth. The
maxillary and mandibular teeth are brushed separately ( Figure 9 ).
7. Horizontal Technique
In the horizontal technique, the teeth are placed edge to edge while the brush
maintains a 90‐degree angle to the long axis of the tooth. The brush is then
moved in a horizontal stroke. This technique is known to cause excessive
toothbrush abrasion ( Figure 10 ).
8. Smith Method
The Smith method is a physiologic technique that follows the pattern that food
follows when it is in the mouth during mas- tication. The bristles are positioned
directly onto the occlusal surface. The brush is then moved back and forth with
the bris- tles reaching from the occlusal surface to the gingiva ( Figure 11 ).

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9. Modified Brushing Technique
In attempts to enhance brushing of the entire facial and lingual tooth surfaces,
the original techniques have been modified. The modified brushing technique
integrates a rolling stroke after use of the vibratory motion to any type of
brushing method. The position of the brush is maintained after the completion
of the original method’s stroke. The bristles are then rolled coronally over the
sgingiva and teeth. During this rolling motion, care should be taken that some of
the filaments reach the interdental areas
Figure 4 Bass technique
Figure 5 Rolling technique
Figure 6 Stillman technique
Figure 7 Charters technique
Figure 8 Fones technique
Figure 9 Leonard technique
Figure 10 Horizontal technique
Figure 11 Smith technique

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Powered Toothbrushes
powered toothbrushes can be categorized as mechanical, sonic, or ionic. A
mechanical brush literally uses the motion of the bristles to remove the plaque
and debris. The sonic toothbrush emits sound waves in addition to the
movement of the filaments. The vibration is said to help loosen the plaque and
food particles for removal. Lastly, the ionic toothbrushes are believed to
temporarily reverse the negative ionic charge of a tooth to a positive charge. A
portion of the toothbrush that is also positively charged is thought to attract the
plaque and food particles away from the tooth, allowing bristles to brush the
loosened particles away. The main patterns of movements in the modern
powered toothbrushes are oscillation, reciprocation, and rotational. The
oscillation movement takes the bristles in a
consistent back‐and‐forth movement. Next
reciprocation moves the bristles up and down or back
and forth. Lastly, rotational movements are circular.
The category of sonic powered toothbrushes refers to
the speed at which the bristles move (Figure 13 ).7
Toothbrushing Time And Frequency
For many years, dental providers advised patients to brush their teeth after every
meal. Research has indicated that, if plaque is completely removed every other
day, no harmful effects will occur in the oral cavity. On the other hand, very
few individuals completely remove plaque; therefore, frequent brushing is still
extremely important and recommended. These repeated brushings will
maximize sulcular cleaning as a measure to control periodontal diseases and
introduce more frequent use of fluoride toothpastes to control caries. In areas
with periodontal pockets, even more frequent oral hygiene procedures are
indicated to decrease infection. Thorough toothbrushing requires a different
amount of time for each individual, depending on such factors as the tendency
Figure 13 Power Toothbrushes

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to accumulate plaque and debris; the individuals psychomotor skills; and the
adequacy of clearance of foods, bacteria, and debris by the saliva. Often a
compromise is made by suggesting 5 to 10 strokes in each area or by advocating
the use of a timer. A patient should be encouraged to brush for up to 2 minutes
and, if necessary, to use a timing device. In addition, many powered
toothbrushes are designed with built in timers that signal the patient when to
move to another area of the mouth; the timers shut off when the designated
number of minutes has passed.8
Toothbrushes Replacement
Toothbrush wear (e.g., splayed, bent, or broken bristles) is influenced more by
the brushing method than by the length of time or number of toothbrushings per
day. The average life of a manual toothbrush is 2 to 3 months. This estimate can
vary greatly depending on brushing habits. It is also sound advice for patients to
have several toothbrushes and to rotate the use of them to ensure use of a dry
brush. Toothbrushes can become contaminated. Drying the toothbrush gives a
less favorable environment for the contaminants to survive. In addition to
regular replacement, replacement after contagious illness is imperative.7
Conclusion
Toothbrushing alone cleans buccal and lingual tooth surfaces. No single
toothbrushing technique adequately cleans occlusal pits and fissures. No
toothbrushing procedure removes all interproximal and subgingival plaque,
especially around malposed teeth and fixed prostheses. Interproximal cleaning
aids are necessary to complete the tooth-cleaning process. No one toothbrush
design has been demonstrated to be most effective for all patients in long-term
studies. Dental professionals should be familiar with various toothbrush
products, primarily from their own use experience, and have examples of
toothbrushes demonstrating various degrees of splaying or bending. These
should be demonstrated when prevention methods are being discussed with their

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patients. Although manufacturers are advertising variations in bristle shape,
bristle size, and number of filaments, no accepted criteria exist for product
labeling. The American Dental Association does not yet consider one
toothbrush design superior to another but is developing clinical-testing
guidelines associated with both plaque and gingivitis reductions. Thoroughness
and frequency of brushing are probably more important than a specific
toothbrushing method and toothbrushing products. Any method that is taught
should be effective, not damaging to the hard or soft tissues, routinely used and
should not cause excessive tooth wear. In initiating effective toothbrushing, it is
necessary to (1) select the appropriate toothbrushes (2) suitable for the patient .
References
1.“Who invented the toothbrush and when was it invented?”The Library of
Congress. 2007‐04‐04. Retrieved April 12, 2008 from
http://www.loc.gov/rr/scitech/mysteries/tooth.html.
2. Golding, P. S. (1982). The development of the toothbrush. A shorthistory of
tooth cleansing. Dent Health (London), 21: 25– 27.
3. Yankell, S. L., & Emling, R. C. (1978). Understanding dental products: What
you should know. Univ Pa Cont Dent Educ, 1: 1– 43.
4. Mintel, T. E., & Crawford, J. (1992). The search for a superior toothbrush
design technology. J Clin Dent, 3: C1– C4.
5. Toothbrush Focus. Dimensions of Dental Hygiene. 2007; 5(5):24–25.)
6. Nathe, Noman O.Harris Franklin Garcia-Godoy Christine Nielsen. Primary
Preventive Dentistry . England, British Library Eighth Edition ( 2014 )
7. Penick, C. (2004). Power toothbrushes: A critical review. Int J Dent Hygiene,
2: 40– 44.
8. Lang, K. P., Cumming, B. R., & Loe, H. (1973). Tooth brushing frequency as
it relates to plaque development and gingival health. J Periodontal, 44:396-405.