Toothbrush technology, dentifrices and dental biofilm ... - IneedCE.com

Earn 

2 CE credits 

This course was 

written for dentists, 

dental hygienists, 

and assistants. 

Toothbrush technology, 

dentifrices and dental 

biofilm removal 

A Peer-Reviewed Publication 

Written by Fiona M. Collins, BDS, MBA, MA 

PennWell designates this activity for 2 Continuing Educational Credits 

Publication date: July 2009 

Go Green, Go Online to take your course 

Review date: April 2011 

Expiry date: March 2014 

This course has been made possible through an unrestricted educational grant. The cost of this CE course is $49.00 for 2 CE credits. 

Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Educational Objectives 

The overall goal of this course is to provide information on 

the removal of plaque (dental biofilm) during home care oral 

hygiene with toothbrushes and dentifrices. 

Upon completion of this course, the clinician will be able to 

do the following: 

1. Decribe dental biofilm development and bacterial 

growth. 

2. Describe the attributes of ideal toothbrushes and 

dentifrices. 

3. List and describe the considerations involved in selecting 

a manual, powered or sonic brush 

4. List and describe the considerations involved in 

dentifrice selection with respect to plaque removal. 

Abstract 

Dental plaque is a complex biofilm consisting of a polysaccharide 

matrix containing bacteria, voids and nonvital material 

of bacterial origin. Both cariogenic and periodontopathic 

bacteria reside in dental biofilm (plaque). While other factors 

must also be present for caries or periodontal disease to exist 

in a patient, without these bacteria neither bacterial disease 

will occur. The primary goal of toothbrushing is to remove 

the dental biofilm present on and adjacent to the teeth, 

thereby removing the bacteria associated with caries and 

periodontal disease; use of a dentifrice while brushing helps 

remove plaque and will also deliver agents to the tooth surface. 

Manual, powered and sonic brushes have all been shown 

to be effective and safe for the removal of plaque, when used 

appropriately. Selecting or recommending oral hygiene aids 

involves a number of considerations, including effectiveness, 

cleaning ability, ease of use and likely compliance. 

Introduction 

Since prehistoric times, man has devised a variety of methods 

to clean and whiten teeth. Some of the earliest devices used 

as “toothbrushes” were similar to some woodstick devices 

currently in use. It was not until the second half of the 20th 

century that first powered and later sonic toothbrushes were 

introduced. Modern toothpaste precursors were developed 

starting in the early 1800s. 1 The development of toothbrushes 

and dentifrices accelerated in the latter half of the 20th century, 

in the search for products ideally suited to their purpose. 

Early efforts at tooth cleaning were focused on making 

teeth look cleaner and whiter and freshening breath. There 

was, however, no understanding of dental biofilm (plaque). 

One of the first people to try to understand the oral ecology 

was Willoughby Miller, who believed that periodontal disease 

was caused by microbes, and who also published an article 

identifying several acidogenic bacteria. 2,3 Seminal research in 

the 1960s and 1970s by Loe 4 and others definitively demonstrated 

the role of plaque as a bacterial ecology involved in the 

development of periodontal disease. Bacteria were also known 

to be associated with caries. 

By the 1980s, it was known that dental plaque consisted of 

a complex environment containing both periodontopathic and 

cariogenic bacteria. The main cariogenic bacteria contained in 

dental biofilm are Streptococcus mutans, with lactobacilli and 

minor bacteria also playing a role. The associations among, 

and proportions of, bacteria change over time as strains that 

are more virulent are introduced. Supragingival plaque contains 

more aerobic bacteria (e.g., Streptococcus mutans) and 

acts as a bacterial reservoir for subgingival plaque. Subgingival 

plaque contains a high proportion of anaerobic bacteria 

(periodontopathogens). Gram-negative anaerobic bacteria 

gradually increase in number and alter the nature of the biofilm. 

Socransky and Hafferjee discovered that dental biofilm 

is made up of specific groupings of bacteria consisting of five 

complexes of varying pathogenicity and virulence. 5,6,7 Three 

periodontopathogens in the red complex of bacteria — T. 

forsythensis, P. gingivalis and T. denticola — are considered 

to be the most common bacteria associated with periodontal 

disease. 8 In mature biofilm, the bacteria are enveloped by the 

biofilm structure, which consists mainly of a polysaccharide 

matrix containing voids as well as nonvital material of bacterial 

origin. It is important to note that periodontal disease will 

not result from the presence of a bacterial infection on its own, 

but involves local and systemic contributing factors and the 

host response. 9 

Reducing, removing or changing the biofilm is carried 

out to try to reduce the bacteria associated with caries and 

periodontal disease, to freshen the breath and for social acceptance. 

A plethora of products is available for these indications, 

including toothbrushes, dentifrices, rinses, creams, and 

professional and prescription products. Agents that have antibacterial 

properties include triclosan/copolymer, essential 

oils, chlorhexidine, xylitol and cetylpyridinium chloride. The 

scope of this article is to address plaque removal. 

Ideal Toothbrush and Dentifrice Properties 

Toothbrushes are designed for dental plaque removal in as 

efficacious a manner as possible, without damaging the hard 

or soft tissues, and dentifrice slurry provides some cleaning 

ability with a toothbrush. 

An ideal toothbrush should effectively and safely remove 

plaque and deliver agents in the dentifrice to the tooth surface. 

It should be easy to use, ergonomic and patient-friendly 

and be able to remove plaque from all surfaces of the tooth, 

including interstitially. For children, the toothbrush can incorporate 

design features that help motivate them to brush. 

An ideal dentifrice should help prevent plaque formation, 

disrupt plaque and optimize plaque removal. It should also 

contain agents that help protect the dentition and periodontal 

tissues; these include agents that prevent demineralization and 

aid remineralization; prevent and reduce periodontal inflammation 

and disease; help prevent oral ulcerations, irritations 

and other oral conditions; and prevent or reduce halitosis. In 

addition, the toothbrush and dentifrice should be effective 

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without damaging the tooth surface or gingivae. Finally, in 

our esthetically conscious society, a toothpaste that improves 

esthetics by whitening the teeth through stain removal, or 

that gives the appearance of whiter teeth, is desirable. 

Table 1. Ideal Properties 

Disrupt and remove plaque effectively 

Reduce plaque 

Prevent and remove stain 

Deliver agents to the tooth surface 

Prevent demineralization 

Aid remineralization 

Prevent and reduce periodontal inflammation 

Prevent oral irritations and ulcerations 

Prevent and reduce halitosis 

Patient-friendly and ergonomic 

Toothbrushes 

The primary objective of toothbrushing is to safely and effectively 

remove dental biofilm from all surfaces of the dentition. 

While patients tend to focus on the buccal and labial aspects 

of the teeth, particularly the upper anterior teeth, since these 

are the areas that are visible and easy-to-reach, plaque removal 

from the lingual and interdental plaque is key; failure to regularly 

remove dental plaque will result in the development of a 

mature biofilm. Typically, brushing and interdental cleaning 

with the adjunctive use of floss or other interdental devices to 

remove plaque interdentally (where a toothbrush cannot reach 

or only partially reaches) are recommended for oral hygiene. 

The primary objective of toothbrushing is the safe 

and effective removal of dental biofilm from all 

surfaces of the dentition. 

Brushing can be achieved using a manual, powered or sonic 

brush. Manual, powered and sonic brushes are all effective at 

removing dental biofilm provided they are used appropriately 

and are well-designed. 10,11,12 Robinson et al. conducted 

a meta-analysis of manual and powered toothbrushes categorized 

by mode of action, finding that the rotation-oscillation 

brushes reduced plaque and gingivitis more than the manual 

brushes, with a 7% reduction in plaque (Quigley-Hein index) 

and a 17% reduction in bleeding-upon-probing (Ainamo Bay 

index) after more than three months. It should be noted that 

one of the criteria was for studies to be 28 days or longer; all 

studies shorter than this or not meeting other criteria were excluded. 

13 A small cross-over study submitted in 2006 involved 

30 days use of each brush (manual, powered or ultrasonic) in 

orthodontic patients and a 15-day washout period between 

use of the different test brushes. Plaque scores were lower on 

the buccal surfaces with brackets when using the ultrasonic 

brush. Strep. Mutans levels were lower using the powered or 

ultrasonic brushes. 14 Compliance with oral hygiene and appropriate 

use of toothbrushes varies 15 , and other factors may 

impact the amount of plaque removed with a given effort. 

When used appropriately, manual, powered and sonic 

brushes can all be effective for dental biofilm removal. 

Historically, for manual brushing patients have been 

taught the Bass technique and to angle the brush so that the 

bristles will be at 45 degrees to the sulcus. The Bass technique 

requires dexterity, patience and knowledge in order to perform 

satisfactorily. More recent manual brushes have been designed 

with the bristles configured at varying angles and lengths to 

overcome the requirement to perform the Bass technique, or 

with handles and grips that result in the bristles being in a 

tilted 45 degree angle and help patients brush. 

Figure 1. Manual brushes 

Powered brushes also require patients to master an appropriate 

technique; however, one advantage of powered brushes in 

general is their ability to remove a greater amount of plaque in 

a given period of time than manual brushes. One study found 

that 75% of dental biofilm was removed in 15 seconds with 

a rotation-oscillation powered brush; the same amount of 

plaque removal required twice as long with a manual brush. 16 

Sonic and powered rotation and rotation-oscillation brushes 

have been found in other studies to also offer superior plaque 

removal compared to manual brushes. 

Figure 2. Powered and sonic brushes 

www.ineedce.com 3

One advantage of powered brushes in general 

is their potential to remove a greater amount of 

plaque in a given time. 

Zimmer et al. compared two sonic brushes with a 

manual toothbrush in a single-blinded crossover study on 

36 teenagers and adults. Each participant sequentially used 

each type of toothbrush for two weeks, with a two-week 

washout period between brush types. Both sonic brushes 

were found to result in superior plaque removal and prevention 

of gingivitis compared to the manual toothbrush. 18 

In a six-month, single-blinded study comparing use of a 

sonic or powered brush by 66 patients, 54 of whom completed 

the study, it was found that supragingival plaque 

removal was greater with the sonic brush. In addition, by 

six months, the reduction in gingival inflammation reached 

31.9% for the sonic brush and 18.1% for the powered brush, 

and probing depth reductions were 15.8% and 7.2%, respectively. 

19 Bader and Boyd found a rotary powered brush 

to be more effective than a sonic brush. 20 A recent in vivo 

single-blinded, randomized crossover study with a sonic 

brush found 88.9% whole-mouth plaque reduction compared 

to the control. 21 

One study compared the volume of dental biofilm and 

fluoride retention following brushing with a rotation-oscillation, 

sonic or manual brush or a manual brush plus flossing. 

Forty-seven subjects were randomized to a sequence of 

trials with each method and used fluoride or fluoride-free 

dentifrice with a washout of seven days between tests. Sonic 

brushing resulted in the least remaining plaque, with a 43% 

to 65% reduction compared to all other treatments. With 

respect to fluoride retention, use of a sonic brush resulted 

in greater fluoride retention from the first day, and after a 

week resulted in 40% greater fluoride concentration than any 

other treatment, the least effective being manual brushing 

and flossing (which demonstrated a reduction in fluoride 

retention on day 1). 22 

Interdental plaque removal 

Interdental cleaning is associated with lack of compliance 

23,24 and has been reported to have relatively poor efficacy 

with a number of methods used. Interdental cleaning 

aids include floss as well as interdental brushes, picks, 

woodsticks and irrigators. 

Floss is known to be difficult for patients to use, which 

can result in inadequate plaque removal even with compliance. 

Some studies have found the efficacy of floss to be 

negligible. 

Separate literature reviews using MEDLINE-PubMed 

and Cochrane database–sourced publications have been 

conducted to determine the effectiveness of interdental aids 

as adjuncts for interproximal plaque removal. For flossing, 

eleven publications met all eligibility criteria. Analysis 

Figure 3. Interdental aids 

showed that in the majority of the studies, no additional 

benefit was seen with the use of floss, and the investigators 

concluded that dental professionals should determine 

for individual patients whether recommending floss is 

useful and if patients can floss adequately. For interdental 

brushes, nine publications were found to meet all inclusion 

criteria, with use of interdental brushes shown to remove 

more interdental plaque than brushing alone, resulting 

in improvements in plaque and bleeding-upon-probing 

scores and probing pocket depth. 25,26 For woodsticks, seven 

publications met all inclusion criteria. It was concluded that 

woodsticks did not reduce the level of interdental plaque 

or improve gingival indices. They were, however, found to 

reduce bleeding. 27 Finally, a separate publication analysis on 

oral irrigation found seven publications that met all inclusion 

criteria. It was found that oral irrigation did not reduce 

visible plaque compared to brushing alone. Nonetheless, 

the researchers were able to conclude from the publications 

that the trend was positive for improvements in gingival 

health with oral irrigation compared to brushing only (Table 

2). 28 The American Dental Association recommends using 

either floss or an interdental cleaner daily. 29 

A sonic subgingival cleaner (soniPick Sonic Interdental 

Plaque Remover) with three bristle lengths was 

introduced as an adjunct to improve plaque removal. In 

vitro testing found that this device resulted in greater subgingival 

plaque removal with any of the bristle tip lengths, 

as measured by removal of artificial plaque from pressuresensitive 

paper inserted 3 mm under mock gingivae, 

compared to use of a manual, multi-tufted, flat toothbrush 

with the bristle tips at a 45 degree angle at the gingival 

margin. 30 Irrespective of efficacy, each of these techniques 

requires an additional step. 


Table 2. Literature review of interdental plaque removal aids 

Flossing 11 studies No additional benefit in majority 

of studies 

Interdental 

brushes 

9 studies Remove more plaque than brushing 

alone 

Improvements in plaque, 

bleeding-upon-probing scores 

and probing pocket depth 

Woodsticks 7 studies Reduced bleeding 

Oral irrigation 7 studies Positive trends in gingival health 

Compared to manual brushes, powered and sonic brushes 

have been found to offer superior interdental plaque removal 

in a number of studies (with the only extra step being a simple 

change of the brush head to an interdental brush head, for 

some models). One study found that use of such a brush head 

in a powered rotation-oscillation brush resulted in superior 

plaque removal and control of gingivitis compared to manual 

brushing plus flossing and use of interdental toothpicks 

(woodsticks). 31 Yankell et al. found in in vitro testing that a 

sonic brush demonstrated greater ability to access interproximal 

areas compared to either a powered brush or a manual 

brush. 32 A recent single-blinded, randomized crossover in 

vivo study with a sonic brush (Spinbrush Sonic) found that 

its use resulted in plaque reduction in hard-to-reach areas 

ranging from 69% to almost 98%. The greatest reductions 

were found in lingual interproximal areas. 33 These results are 

significant given the inability of patients to reach difficult-toaccess 

areas of the dentition. 

Compared to manual brushes, powered and sonic brushes 

have been found to offer superior interdental 

plaque removal. 

effects was use of a sonic toothbrush and an electric interdental 

flosser, mainly attributable to the flosser, and only in 

patients with poor oral hygiene. 35 In another study, use of a 

sonic toothbrush resulted in a 57% reduction of supragingival 

plaque in orthodontic patients who had gingivitis, versus 10% 

for manual brushing. 36 Costa et al. also studied plaque and 

gingival indices for reductions with either manual or sonic/ 

ultrasonic brushes. Both types were found to provide reductions; 

however, for orthodontic and dental implant patients, a 

greater reduction was found with sonic brushes. 37 

For children, the more attractive and easier a brush is 

to use, the more, in principle, they will be motivated to use 

the brush. For this reason, children’s manual and powered 

toothbrush designs have incorporated pop culture characters 

and names, flashing lights, tunes, and other visual and aural 

displays aimed at attracting children. 

Figure 4. Pediatric manual brushes 

Figure 5. Pediatric powered brushes 

Orthodontic patients and children 

Powered and sonic brushes may offer help to orthodontic 

patients and children who do not brush for long enough or 

may have difficulty brushing manually. Comparative studies 

have been conducted in vitro, in situ and in vivo with 

orthodontic patients on the use of manual, powered and 

sonic brushes as well as interdental aids. Sander et al. assessed 

the ability of sonic and rotating brushes to remove artificial 

plaque in vitro from plastic surfaces simulating teeth with 

multibracket appliances. The reduction in plaque was determined 

using before and after photo analysis. In this study, it 

was found that brushing efficacy, defined as plaque removal, 

was dependent not on the type of brush but on the individual 

brush. The investigators also concluded that longer brushing 

times and mastery of a proper brushing technique were still 

required. 34 In orthodontic patients, a comparison of manual 

and sonic toothbrushes, sonic toothbrush plus an electronic 

interdental flosser, and sonic toothbrush plus manual flossing 

was documented; while improvements occurred in the first 

four weeks, the only treatment regimen offering longer-term 

One concern with powered and sonic brushes has been their 

effect on the shear bond strength of orthodontic brackets. A 

number of in vitro studies has been conducted concluding 

that use of powered and sonic brushes did not negatively 

influence the shear-bond strength of orthodontic brackets. 

Garcia-Godoy and de Jager, in an in vitro study using orthodontic 

brackets bonded to the enamel surface of extracted 

teeth, determined that the shear bond strengths were the 

same whether manual, sonic or powered brushes were used in 

a method equivalent to two years of regular use. 38 Ultrasound 


toothbrushes and rotation-oscillation toothbrushes were also 

found in in vitro studies to be safe for orthodontic brackets 

and dental restorations. No significant effect was found on 

orthodontic brackets with any of the brushes tested. 39 

Sonic toothbrushes and mechanism of action 

Sonic toothbrushes utilize the principles of fluid dynamics 

to accomplish dental biofilm removal. A study assessing 

the ability of fluid pressure and dynamic shear forces to remove 

dental biofilm was conducted by Stanford et al. In situ 

samples were allowed to develop dental biofilm for 16 hours, 

then removed and tested in vitro for 5, 10 or 15 seconds with 

the bristles held 2 mm or 3 mm from the surface. After brushing, 

the residual bacterial count was assessed. Similar testing 

was performed with another electric toothbrush held 3 mm 

from the surface of similar samples. Plaque reduction using 

the sonic brush was 56% to 78% compared to control samples, 

and no reduction was found using the electric toothbrush 3 

mm from the tooth surface. (It should be noted that powered 

brushes are not intended for use 3 mm from the tooth surface.) 

The investigators also assessed the results using scanning 

electron microscopy and concluded that sonic toothbrushes 

could remove dental biofilm through fluid dynamics when 

held up to 3 mm from the tooth surface. 40 Another study 

confirmed that using airy bubbles against mature dental 

biofilm on a solid surface resulted in removal of the biofilm 

where the bubbles collided with it. The amount removed in 

a given time was found to vary with the rate of collision of 

the bubbles against the biofilm and the surface area of the 

bubbles. The investigators attributed the biofilm removal to 

fluid dynamic shear forces and determined that a fast bubbly 

flow could be expected to remove biofilm. 41 Parini et al. found 

that low-velocity flowing bubbles in fluid could remove a film 

of Streptococcus mutans from a glass surface better than fluid 

in the absence of bubbles. 42 

Sonic toothbrushes can remove dental biofilm 

through fluid dynamics when held up to 3 mm from 

the tooth surface. 

It has been hypothesized that sonic brush-head motion 

would generate bubbles in a dentifrice so that ultrasound 

beamed into the slurry would cause the bubbles to expand and 

contract in a manner that would dislodge the plaque bacteria 

adherent to the tooth surface. Pitt conducted an experiment 

in which a submerged biofilm of Streptococcus mutans was 

subjected to sonic energy between 80 and 1000 Hertz. It was 

found that the intensity of the acoustics influenced biofilm 

removal when convective fluid flow was present, but that 

removal was negligible without this fluid flow (up to 2% over 

10 minutes). Introducing gas bubbles into the fluid resulted 

in almost 100% biofilm removal with intensive sonic activity. 

43 Pitt et al. concluded from their in vitro study on dental 

biofilm and sonic acoustic waves that the dynamics of fluid 

flow with bubbles can be expected to remove dental biofilm in 

vivo and recommended maximum fluid velocity. 44 It has also 

been found that bubbles are most effective when they collide 

with the biofilm at an angle of between 5 and 45 degrees. 45 

Busscher et al. concluded that a high percentage of bacterial 

pairs that were adherent to each other were removed by 

noncontact sonic brushing at a distance of up to 6 mm from 

the surface on which the bacteria had colonized. 46 In a similar 

study, electric, manual and sonic brushes were compared for 

their ability to remove adhering and nonadhering streptococci 

and actinomyces. It was found that sonic brushes removed almost 

all adhering bacterial pairs, while manual and powered 

brushes did not and removed less of the coadhering than the 

nonadhering bacteria. It was also found that the presence of 

fluoride was immaterial to the amount of bacteria removed by 

any of the tested brushing methods. 47 

Increasing the rate of flow in a fluid overlying biofilm has 

been found to result in increased delivery of the agent to 

penetrate and cross the layer of biofilm. 

A recent literature review by Stoodley et al. on the mass 

transport of agents to the biofilm and teeth found that dental 

biofilm influences the delivery of caries preventives, specifically 

fluoride. It was found that increasing the rate of flow in 

a fluid overlying biofilm resulted in increased delivery of the 

agent to penetrate and cross the layer of biofilm. 48 

Figure 6. Action of sonic toothbrushes 

Mechanical – Brush contact 

Fluid Dynamics 

Bubbles 

Biofilm Removal 


Dentifrices 

Plaque reduction can be achieved by the mechanical activity 

of toothpaste slurry in combination with a toothbrush and/ 

or by using chemotherapeutic agents to reduce the volume 

of plaque. Soft or ultra-soft toothbrush bristles are recommended. 

Studies have variously demonstrated greater or 

lesser abrasivity with manual or powered brushes, notably 

on eroded (demineralized) dental hard tissue. 49,50 However, 

it was found that, specifically with regard to erosion, the 

abrasiveness of toothpaste slurry was more predictive of 

abrasion than the stiffness of the filaments of manual brushes. 

51 The abrasives in modern dentifrices consist of fine, 

rounded particles that gently help remove dental biofilm 

and stain. Frequently used cleaning agents in dentifrices include 

baking soda (sodium bicarbonate), calcium carbonate 

and calcium phosphate. The radioactive dentin abrasivity 

(RDA) of current dentifrices is typically in the range of 70 

to 100 RDA, Dentifrices with an RDA of 70 to 110 are safe 

and effective for dental biofilm and stain removal when used 

appropriately with a toothbrush, as are baking soda dentifrices 

with a lower RDA. While it has low abrasivity, baking 

soda has excellent cleaning ability even when compared to 

higher-RDA agents. 52 Clinical trials with use of a manual 

brush with baking soda dentifrices at concentrations ranging 

from 20% to 65% demonstrated baking soda’s ability to 

remove plaque. Increased plaque reduction was found with 

baking soda dentifrice, with higher concentration of baking 

soda resulting in more plaque reduction. In addition, 

for all concentrations of baking soda, incremental plaque 

reduction was found on the harder-to-reach-and-brush 

proximal and lingual surfaces. It is believed that cleaning 

power rather than abrasivity is an important factor in the 

effectiveness of baking soda. Baking soda readily dissolves 

intraorally and is known to impart a “clean” feeling. The 

investigators suggested that the large, soft crystals of baking 

soda may displace plaque more than other dentifrices or 

may affect the biofilm’s polysaccharide matrix, or the baking 

soda may disrupt bacterial adhesion by blocking calcium 

bonds involved in co-adhesion and simultaneously release 

calcium dioxide gas. 53 

The inclusion of baking soda in dentifrices has been 

found to benefit plaque removal, especially 

in hard-to-reach areas. 

Another option that has been investigated is intraoral 

recharging with liquid toothpaste onto the brush head during 

brushing. This was found in a small, single-blinded, 

randomized crossover study to result in a greater reduction 

of colony-forming bacteria and gram-negative anaerobes 

compared to conventional brushing without redosing, and 

also an increase in the amount of surfactant present in the 

gingival crevicular fluid. 54 Interestingly, Lea et al. found that 

the load (0, 1 or 2 Newtons) and toothpaste used for powered 

toothbrushing significantly influenced the bristle vibration 

of the brush. The study used scanning laser vibrometry to 

determine the effects of sonic and other powered brushes. For 

all brushes except the Sonicare, the displacement amplitudes 

of the bristles were affected by a load of 1 Newton without 

use of toothpaste; with toothpaste, all brushes were affected. 

This could be expected to influence the performance of powered 

brushes. 55 

Education 

It is not uncommon for patients to attempt to use powered 

and sonic brushes similarly to the way they use manual 

brushes, moving them in a horizontal manner across the 

teeth and disregarding the movement generated by power, 

and applying too much load (which would typically result in 

stalling). Patients may say “ I didn’t like the electric toothbrush 

and couldn’t get used to it” for that very reason. The 

importance of educating patients on the use of any type of 

toothbrush, not just manual brushes, was underscored in a 

study by Renton-Harper et al. They found that uninstructed 

de novo use of two different rotation-oscillation brushes 

and one manual brush resulted in no difference in plaque 

reduction during the early period of usage. 56 Whether a 

manual, powered or sonic brush is recommended for a given 

patient, oral hygiene instruction and instructions on use of 

the toothbrush are required. 

Summary 

Since prehistoric times, man has devised a variety of methods 

to clean and whiten the teeth. Toothbrushes are designed 

for dental plaque (biofilm) removal in as efficacious and safe 

a manner as possible, with dentifrices offering cleaning 

ability when used with toothbrushes, as well as delivery 

of preventives and other agents. When used appropriately, 

manual, powered and sonic brushes can all be effective for 

dental biofilm removal. One advantage of powered and 

sonic brushes in general is their ability to remove a greater 

amount of plaque in a given period of time and to aid interdental 

cleaning. Sonic brushes have been shown to have 

the ability to also remove dental biofilm when held a slight 

distance from the tooth surface and to help in the delivery of 

dentifrice agents. 

References 

1 A brief history of your toothbrush, toothpaste and oral 

hygiene. Available at: www.associated content.com/ 

article/164851/a_brief_history_of_your_toothbrush. 

html. Accessed May 10, 2009. 

2 Miller WD. The human mouth as a focus of infection. 

Dent Cosmos. 1891;33:689,789,913. 

3 Miller WD. The microorganisms of the human 

mouth: The local and general which are caused by 

them. The SS White Dental Manufacturing Company, 

Philadelphia, 1890. 


4 Löe H, Theilade E, Jensen SB. Experimental gingivitis 

in man. J Periodontol. 1965;36:177–87. 

5 American Academy of Periodontology Research, 

Science and Therapy Committee Position Paper: 

Epidemiology of periodontal diseases. J Periodontol. 

2005;76:1406–19. 

6 Socransky SS, Haffajee AD, et al. Microbial 

complexes in subgingival plaque. J Clin Periodontol. 

1998;25:134–144. 

7 Lovegrove JM. Dental plaque revisited: bacteria 

associated with periodontal disease. J NZ Soc 

Periodontol. 2004;87:7–21. 

8 Socransky SS, Haffajee AD, et al. Microbial 

complexes in subgingival plaque. J Clin Periodontol. 

1998;25:134–44. 

9 Nield-Gehrig JS, Willmann DE. Search for the Causes 

of Periodontal Disease, in Foundations of Periodontics 

for the Dental Hygienist, second edition. Philadelphia: 

Lippincott, Williams & Williams; 2008. 

10 Haffajee AD, Smith C, Torresyap G, Thompson M, 

Guerrero D, Socransky SS. Efficacy of manual and 

powered toothbrushes (II). Effect on microbiological 

parameters. J Clin Periodontol. 2001;28(10):947–54. 

11 Bader HI, Boyd RL. Comparative efficacy of a rotary 

and a sonic-powered toothbrush on improving 

gingival health in treated adult periodontitis patients. 

Am J Dent. 1999;12(3):143–7. 

12 Warren P, Thompson M, Cugini M. Plaque removal 

efficacy of a novel manual toothbrush with MicroPulse 

bristles and an advanced split-head design. J Clin 

Dent. 2007;18(2):49–54. 

13 Robinson PG, Deacon SA, Deery C, et al. Manual 

versus powered toothbrushing for oral health. 

Cochrane Database Syst Rev. 2005;18(2):CD002281. 

14 Costa MR, Silva VC, Miqui MN, et al. Efficacy of 

Ultrasonic, Electric and Manual Toothbrushes in 

Patients with Fixed Orthodontic Appliances. Angle 

Orthod. 2007;77(2):361-366. 

15 McCracken G, Janssen J, Heasman L, et al. Assessing 

adherence with toothbrushing instructions using a 

data logger toothbrush. Br Dent J. 2005;198(1):29-32. 

16 Preber H, Ylipaa V, Bergstrom J, Ryden H. A 

comparative study of plaque removing efficiency 

using rotary electric and manual toothbrushes. Swed 

Dent J. 1991;15:229–234. 

17 Tritten CB, Armitage GC. Comparison of a sonic 

and a manual toothbrush for efficacy in supragingival 

plaque removal and reduction of gingivitis. J Clin 

Periodontol. 1996;23(7):641–648. 

18 Zimmer S, Fosca M, Roulet JF. Clinical study of the 

effectiveness of two sonic toothbrushes. J Clin Dent. 

2000;11(1):24–7. 

19 Robinson PJ, Maddalozzo D, Breslin S. A six-month 

clinical comparison of the efficacy of the Sonicare and 

the Braun Oral-B electric toothbrushes on improving 

periodontal health in adult periodontitis patients. J 

Clin Dent. 1997;8(1 Spec No):4–9. 

20 Bader HI, Boyd RL. Comparative efficacy of a rotary 

and a sonic powered toothbrush on improving 

gingival health in treated adult periodontitis patients. 

Am J Dent. 1999;12(3):143–147. 

21 Data on file. 

22 Sjögren K, Lundberg AB, Birkhed D, Dudgeon 

DJ, Johnson MR. Interproximal plaque mass and 

fluoride retention after brushing and flossing: a 

comparative study of powered toothbrushing, manual 

toothbrushing and flossing. Oral Health Prev Dent. 

2004;2(2):119–24. 

23 w w w. d o c e r e . c o m / H y g i e n e t o w n / A r t i c l e . 

HygieneTown Survey. July 2005. 

24 Craig T, Montigue J. Family oral health survey. J Am 

Dent Assoc. 1976;92:326–332. 

25 Berchier CE, Slot DE, Haps S, Van der Weijden GA. 

The efficacy of dental floss in addition to a toothbrush 

on plaque and parameters of gingival inflammation: a 

systematic review. Int J Dent Hyg. 2008;6(4):265–79. 

26 Slot DE, Dörfer CE, Van der Weijden GA.The efficacy 

of interdental brushes on plaque and parameters of 

periodontal inflammation: a systematic review. Int J 

Dent Hyg. 2008;6(4):253–64. 

27 Hoenderdos NL, Slot DE, Paraskevas S, Van der 

Weijden GA. The efficacy of woodsticks on plaque 

and gingival inflammation: a systematic review. Int J 

Dent Hyg. 2008;6(4):251–2. 

28 Husseini A, Slot DE, Van der Weijden GA. The 

efficacy of oral irrigation in addition to a toothbrush 

on plaque and the clinical parameters of periodontal 

inflammation: a systematic review. Int J Dent Hyg. 

2008;6(4):304–14. 

29 American Dental Association. Oral health topics A-Z. 

Cleaning your teeth and gums. Available at: http:// 

www.ada.org/public/topics/cleaning.asp 

30 Yankell SL, Shi X, Emling RC, Bock RT. Subgingival 

access and artificial plaque removal by a sonic cleaning 

device. J Clin Dent. 1999;10(4):139–42. 

31 Murray PA, Boyd RL, Robertson PB. Effect on 

periodontal status of rotary electric toothbrushes 

vs. manual toothbrushes during periodontal 

maintenance. II, Microbiological results. J 

Periodontol. 1989;60(7):396–401. 

32 Yankell SL, Emling RC, Shi X. Interproximal access 

efficacy of Sonicare Plus and Braun Oral-B Ultra 

compared to a manual toothbrush. J Clin Dent. 

1997;8(1 Spec No):26–9. 

33 Data on file. 

34 Sander FM, Sander C, Toth M, Sander FG. Dental 

care during orthodontic treatment with electric 

toothbrushes. J Orofac Orthop. 2006;67(5):337–45. 


35 Kossack C, Jost-Brinkmann PG. Plaque and gingivitis 

reduction in patients undergoing orthodontic treatment 

with fixed appliances: comparison of toothbrushes 

and interdental cleaning aids, A 6-month clinical 

single-blind trial. J Orofac Orthop. 2005;66(1):20–38. 

36 Ho HP, Niederman R. Effectiveness of the Sonicare 

sonic toothbrush on reduction of plaque, gingivitis, 

probing pocket depth and subgingival bacteria in 

adolescent orthodontic patients. J Clin Dent. 1997;8(1 

Spec No):15–9. 

37 Costa MR, Marcantonio RA, Cirelli JA. Comparison 

of manual versus sonic and ultrasonic toothbrushes: a 

review. Int J Dent Hyg. 2007;5(2):75–81. 

38 García-Godoy F, de Jager M. Effect of manual and 

powered toothbrushes on orthodontic bracket bond 

strength. Am J Dent. 2007;20(2):90–2. 

39 Sorensen JA, Pham MM, McInnes C. In vitro safety 

evaluation of a new ultrasound power toothbrush. J 

Clin Dent. 2008;19(1):28–32. 

40 Stanford CM, Srikantha R, Wu CD. Efficacy of the 

Sonicare toothbrush fluid dynamic action on removal 

of human supragingival plaque. J Clin Dent. 1997;8(1 

Spec No):10–4. 

41 Parini MR, Pitt WG. Dynamic removal of oral 

biofilms by bubbles. Colloids Surf B Biointerfaces. 

2006;52(1):39–46. 

42 Parini MR, Eggett DL, Pitt WG. Removal of 

Streptococcus mutans biofilm by bubbles. J Clin 

Periodontol. 2005;32(11):1151–6. 

43 Pitt WG. Removal of oral biofilm by sonic phenomena. 

Am J Dent. 2005;18(5):345–52. 

44 Ibid. 

45 Parini MR, Pitt WG. Removal of oral biofilms by 

bubbles: the effect of bubble impingement angle and 

sonic waves. J Am Dent Assoc. 2005;136(12):1688–93. 

46 Busscher HJ, Rustema-Abbing M, Bruinsma GM, de 

Jager M, Gottenbos B, van der Mei HC. Non-contact 

removal of coadhering and non-coadhering bacterial 

pairs from pellicle surfaces by sonic brushing and de 

novo adhesion. Eur 2003;111(6):459–64. 

47 Yang J, Bos R, Belder GF, Busscher HJ. Co-adhesion 

and removal of adhering bacteria from salivary 

pellicles by three different modes of brushing. Eur 

2001;109(5):325–9. 

48 Stoodley P, Wefel J, Gieseke A, Debeer D, von Ohle 

C. Biofilm plaque and hydrodynamic effects on mass 

transfer, fluoride delivery and caries. J Am Dent 

Assoc. 2008;139(9):1182–90. 

49 Wiegand A, Lemmrich F, Attin T. Influence of 

rotating-oscillating, sonic and ultrasonic action of 

power toothbrushes on abrasion of sound and eroded 

dentine. J Periodontal Res. 2006;41(3):221–7. 

50 Wiegand A, Begic M, Attin T. In vitro evaluation of 

abrasion of eroded enamel by different manual, power 

and sonic toothbrushes. Caries Res. 2006;40(1):60–5. 

51 Wiegand A, Schwerzmann M, Sener B, Magalhaes 

AC, Roos M, et al. Impact of toothpaste slurry 

abrasivity and toothbrush filament stiffness on 

abrasion of eroded enamel: an in vitro study. Acta 

Odontol Scand. 2008;66(4):231–5. 

52 International Standards Organization 11609, 1995. 

Dentistry: toothpaste—requirements, test methods 

and marking. 

53 Putt MS, Milleman KR, Ghassemi A, Vorwerk L, 

Hooper WJ, et al. Enhancement of plaque removal 

efficacy by tooth brushing with baking soda 

dentifrices: Results of five clinical studies. J Clin Dent. 

2008;21(4):111–26. 

54 Barlow AP, Zhou X, Barnes JE, Hoke SH, Eichhold 

TH, et al. Pharmacodynamic and pharmacokinetic 

effects in gingival crevicular fluid from re-dosing 

during brushing. Compend 2004;10 (Suppl 1):21–7. 

55 Lea SC, Khan A, Patanwala HS, Landini G, Walmsley 

AD. The effects of load and toothpaste on powered 

toothbrush vibrations. J Dent. 2007;35(4):350–4. 

56 Renton-Harper P, Addy M, Newcombe RG. 

Plaque removal with the uninstructed use of electric 

toothbrushes: comparison with a manual brush and 

toothpaste slurry. J Clin Periodontol. 2001;28(4): 

325–30. 

Author Profile 

Fiona M. Collins, BDS, MBA, MA 

Dr. Fiona M. Collins has authored 

and presented CE courses to dental 

professionals and students in 

the US and internationally. She is 

a past-member of the Academy 

of General Dentistry Foundation 

Strategy Board, has been a member 

of the British Dental Association, 

the Dutch Dental Association, the American Dental Association, 

the International Association for Dental Research, 

and is a member of the Organization for Asepsis and Safety 

Procedures. Dr. Collins earned her dental degree from 

Glasgow University and holds an MBA and MA from 

Boston University. 

Disclaimer 

The author(s) of this course has/have no commercial ties with 

the sponsors or the providers of the unrestricted educational 

grant for this course. 

Reader Feedback 

We encourage your comments on this or any PennWell course. 

For your convenience, an online feedback form is available at 

www.ineedce.com. 


1. First powered and later sonic toothbrushes 

were introduced in _________. 

a. the second half of the 19th century 

b. the first half of the 20th century 

c. the second half of the 20th century 

d. none of the above 

2. Seminal research in the _________ by 

Loe and others definitively demonstrated 

the role of plaque as a bacterial ecology 

involved in the development of periodontal 

disease. 

a. 1930s and 1940s 

b. 1940s and 1950s 

c. 1960s and 1970s 

d. all of the above 

3. Supragingival plaque _________ 

subgingival plaque. 

a. contains more aerobic bacteria than 

b. acts as a bacterial reservoir for 

c. consists predominantly of periodontopathic 

bacteria 

d. a and b 

4. In mature biofilm, _________. 

a. the biofilm structure consists mainly of a polysaccharide 

matrix containing voids as well as nonvital 

material of bacterial origin 

b. the bacteria are enveloped by the biofilm structure 

c. no aerobic bacteria are found 


5. _________ has antibacterial properties. 

a. Triclosan/copolymer 

b. Cetylpyridinium chloride 

c. Chlorhexidine 


6. Reducing, removing or changing the 

biofilm is carried out _________. 

a. to try to reduce the bacteria associated with caries 

and periodontal disease 

b. to freshen the breath 

c. for social acceptance 


7. An ideal dentifrice should help _________. 

a. prevent plaque formation 

b. disrupt plaque 

c. optimize plaque removal 


8. An ideal toothbrush should _________. 

a. effectively and safely remove plaque from all 

surfaces of the tooth 

b. be easy to use, ergonomic and patient-friendly 

c. deliver agents in the dentifrice to the tooth surface 


9. _________ brushes are effective at removing 

dental biofilm provided they are used 

appropriately. 

a. Manual 

b. Powered 

c. Sonic 


10. Historically, patients have been taught 

the _________ and to angle the brush so 

that the bristles will be at 45 degrees to 

the sulcus. 

a. Postillo technique 

b. Bass technique 

c. Base technique 

d. Bassist technique 

11. More recent manual brushes include 

designs with handles and grips that result 

in the bristles being in a tilted _________. 

a. 15 degree angle 

b. 35 degree angle 

c. 45 degree angle 

d. 95 degree angle 

Questions 

12. Robinson et al. found from their metaanalysis 

that rotation-oscillation brushes 

reduced plaque and gingivitis _________ 

manual brushes. 

a. less than 

b. as much as 

c. more than 


13. One study found that _________ of 

dental biofilm was removed in _________ 

seconds with a rotation-oscillation 

powered brush; the same amount of 

plaque removal required twice as long 

with a manual brush. 

a. 65%; 15 

b. 75%; 10 

c. 75%; 15 

d. 85%; 15 

14. _________ et al. compared two sonic 

brushes with a manual toothbrush in a 

single blinded crossover study and found 

the sonic brushes to remove more plaque. 

a. Timmer 

b. Zimmer 

c. Zimmerman 

d. Timmerman 

15. With respect to fluoride retention, use 

of a_________ brush resulted in greater 

fluoride retention than use of a _________ 

brush in one study. 

a. powered; sonic or manual 

b. manual; powered or sonic 

c. sonic; powered or manual 

d. none of the above, all were equal 

16. Berchier et al. found in a meta-analysis 

that no additional benefit was seen with 

the use of floss, and the investigators 

concluded that dental professionals 

should _________. 

a. recommend the use of floss for all patients 

b. determine for individual patients whether recommending 

floss is useful and if patients can floss 

adequately 

c. not recommend flossing 


17. Yankell et al. found in in vitro testing that 

a _________ demonstrated the greatest 

access to interproximal areas. 

a. sonic brush 

b. powered brush 

c. manual brush 


18. Children’s manual and powered 

toothbrush designs have incorporated 

_________. 

a. pop culture characters and names 

b. flashing lights 

c. tunes 


19. Powered brushes have been found to be 

_________ for orthodontic brackets. 

a. unsafe 

b. safe 

c. useless 


20. Sonic toothbrushes utilize the principles 

of _________ to accomplish dental biofilm 

removal. 

a. hydrotherapy 

b. fluid dynamics 

c. electromagnetic forces 


21. Using scanning electron microscopy, 

Stanford et al. concluded that sonic 

toothbrushes could remove dental biofilm 

through fluid dynamics __________. 

a. only when in contact with the tooth surface 

b. when held at a distance of up to 1 mm from the 

tooth surface 

c. when held at a distance of up to 2 mm from the 

tooth surface 

d. when held at a distance of up to 3 mm from the 

tooth surface 

22. Increasing the rate of flow in a fluid 

overlying biofilm has been found to result 

in _________ delivery of the agent. 

a. decreased 

b. regular 

c. increased 


23. Specifically with regard to erosion, the 

abrasiveness of toothpaste slurry has been 

found by investigators to be _________ 

predictive of abrasion than the stiffness of 

the filaments of brushes. 

a. less 

b. as 

c. more 


24. It is believed that _________ is an 

important factor in the effectiveness of 

baking soda. 

a. cleaning power 

b. abrasivity 

c. strength 


25. Intraoral recharging with liquid toothpaste 

onto the brush head during brushing 

has been found to result in _________. 

a. a greater reduction of colony-forming bacteria 

b. an increase in the amount of surfactant present in 

the gingival 

crevicular fluid 

c. a lower reduction of colony-forming bacteria 


26. It has been hypothesized that baking 

soda may affect the biofilm’s _________. 

a. polysaccharide matrix 

b. polyol concentration 

c. polyol matrix 


27. If a _________ brush is recommended for 

a given patient, oral hygiene instruction 

should be provided on its use. 

a. manual 

b. sonic 

c. powered 


28. Uninstructed de novo use of rotationoscillation 

and manual brushes was 

found in one study to result in _________ 

difference in plaque reduction during the 

early period of usage. 

a. no 

b. a barely significant 

c. a very significant 


29. _________ is a frequently used cleaning 

agent in dentifrices. 

a. Calcium carbonate 

b. Baking soda 

c. Calcium phosphate 


30. The American Dental Association 

recommends using _________ daily. 

a. floss 

b. an interdental cleaner 

c. a brush 

d. a or b 


ANSWER SHEET 

Toothbrush technology, dentifrices and dental biofilm removal 

Name: Title: Specialty: 

Address: 

E-mail: 

City: State: ZIP: Country: 

Telephone: Home ( ) Office ( ) 

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all 

information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn 

you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822 

Educational Objectives 

1. Describe dental biofilm development and bacterial growth. 

2. Describe the attributes of ideal toothbrushes and dentifrices. 

3. List and describe the considerations involved in selecting a manual, powered or sonic brush. 

4. List and describe the considerations involved in dentifrice selection with respect to plaque removal. 

Course Evaluation 

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 

1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No 

Objective #2: Yes No Objective #4: Yes No 

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 

Mail completed answer sheet to 

Academy of Dental Therapeutics and Stomatology, 

A Division of PennWell Corp. 

P.O. Box 116, Chesterland, OH 44026 

or fax to: (440) 845-3447 

For immediate results, 

go to www.ineedce.com to take tests online. 

Answer sheets can be faxed with credit card payment to 

(440) 845-3447, (216) 398-7922, or (216) 255-6619. 

Payment of $49.00 is enclosed. 

(Checks and credit cards are accepted.) 

If paying by credit card, please complete the 

following: MC Visa AmEx Discover 

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Exp. Date: _____________________ 

Charges on your statement will show up as PennWell 

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 

7. Was the overall administration of the course effective? 5 4 3 2 1 0 

8. Do you feel that the references were adequate? Yes No 

9. Would you participate in a similar program on a different topic? Yes No 

10. If any of the continuing education questions were unclear or ambiguous, please list them. 

___________________________________________________________________ 

11. Was there any subject matter you found confusing? Please describe. 

___________________________________________________________________ 

___________________________________________________________________ 

12. What additional continuing dental education topics would you like to see? 

___________________________________________________________________ 

___________________________________________________________________ 

AGD Code 017, 557 

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. 

AUTHOR DISCLAIMER 

The author(s) of this course has/have no commercial ties with the sponsors or the providers of 

the unrestricted educational grant for this course. 

SPONSOR/PROVIDER 

This course was made possible through an unrestricted educational grant. No 

manufacturer or third party has had any input into the development of course content. 

All content has been derived from references listed, and or the opinions of clinicians. 

Please direct all questions pertaining to PennWell or the administration of this course to 

Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com. 

COURSE EVALUATION and PARTICIPANT FEEDBACK 

We encourage participant feedback pertaining to all courses. Please be sure to complete the 

survey included with the course. Please e-mail all questions to: macheleg@pennwell.com. 

INSTRUCTIONS 

All questions should have only one answer. Grading of this examination is done 

manually. Participants will receive confirmation of passing by receipt of a verification 

form. Verification forms will be mailed within two weeks after taking an examination. 

EDUCATIONAL DISCLAIMER 

The opinions of efficacy or perceived value of any products or companies mentioned 

in this course and expressed herein are those of the author(s) of the course and do not 

necessarily reflect those of PennWell. 

Completing a single continuing education course does not provide enough information 

to give the participant the feeling that s/he is an expert in the field related to the course 

topic. It is a combination of many educational courses and clinical experience that 

allows the participant to develop skills and expertise. 

COURSE CREDITS/COST 

All participants scoring at least 70% on the examination will receive a verification 

form verifying 2 CE credits. The formal continuing education program of this sponsor 

is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for 

current term of acceptance. Participants are urged to contact their state dental boards 

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