Finding an upper limit of what might be achievable by patients: oral cleanliness in dental professionals after self-performed manual oral hygiene

Manual toothbrushing techniques for plaque removal and the prevention of gingivitis-A systematic review with network meta-analysis

BACKGROUND

The meaning of the toothbrushing technique for the effectivity of toothbrushing in terms of plaque removal and parameters of gingivitis is unknown. This systematic review and network meta-analysis (NMA) aimed to synthesize evidence from randomized controlled trials (RCTs).

METHODS

We searched MEDLINE (PubMed), the Cochrane Central Register of Controlled Trials, and the Web of Science for RCTs that compared any self-applied manual toothbrushing technique to any other technique or control and assessed plaque after toothbrushing and gingivitis. Where intervention effects were recorded repeatedly, the last post-intervention assessment was treated as the primary outcome date (POD), and the assessment closest to the intervention as the secondary outcome date (SOD). Age restrictions were not imposed. Participants with fixed orthodontic appliances were excluded. The evidence was evaluated using the Confidence in Network Meta-Analyses (CINeMA) approach, which is based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Thirteen publications, including 15 studies, were identified. Ten studies assessing the Fones, Bass, and Scrub techniques provided data eligible for the NMA. The confidence rating of the evidence varied from very low to high in the case of plaque, and from very low to low in the case of gingivitis. Regarding PODs, Fones probably reduces plaque slightly compared with no training; the evidence is very uncertain that Fones may have little to no effect on gingivitis. Bass may result in little to no difference in plaque; the evidence that Bass may result in a slight increase in gingivitis is very uncertain. The evidence is very uncertain that Scrub may result in little to no difference in plaque at the SOD (no POD-data available) and that it may result in a slight increase in gingivitis.

CONCLUSION

There is limited evidence regarding the effects of toothbrushing techniques on plaque after brushing or gingivitis.

"You should brush your teeth better": a randomized controlled trial comparing best-possible versus as-usual toothbrushing

BACKGROUND

Most people's tooth brushing performance is deficient, even when they are encouraged to brush to the best of their abilities. The aim of the present study was to explore the nature of this deficit by comparing best-possible vs. as-usual brushing.

METHODS

University students (N = 111) were randomly assigned to receive one of two instructions: "brush your teeth as usual" (AU-instruction) or "brush your teeth to the best of your abilities" (BP-instruction). Video analyses assessed brushing performance. The marginal plaque index (MPI) assessed after brushing was used as an indicator of brushing effectiveness. A questionnaire assessed subjectively perceived oral cleanliness (SPOC).

RESULTS

Participants in the BP group brushed their teeth longer (p = 0.008, d = 0.57) and used interdental devices more often (p < 0.001). No group differences emerged in the distribution of brushing time among surfaces, the percentage of brushing techniques used beyond horizontal scrubbing, or the appropriate use of interdental devices (all p > 0.16, all d < 0.30). Plaque persisted at the majority of the sections of the gingival margins, and the groups did not differ in this respect (p = 0.15; d = 0.22). SPOC values in the BP group were higher than those in the AU group (p = 0.006; d = 0.54). Both groups overestimated their actual oral cleanliness by approximately twofold.

CONCLUSIONS

Compared to their usual brushing effort, study participants increased their effort when asked to brush their teeth in the best possible manner. However, that increase in effort was ineffective in terms of oral cleanliness. The results indicate that people's concept of optimized brushing refers to quantitative aspects (e.g., longer duration, more interdental hygiene) rather than qualitative aspects (e.g., considering inner surfaces and gingival margins, appropriate use of dental floss).

TRIAL REGISTRATION

The study was registered in the appropriate national register ( www.drks.de ; ID: DRKS00017812; date of registration: 27/08/2019 - retrospectively registered).

Periodontal Management in Periodontally Healthy Orthodontic Patients with Fixed Appliances: An Umbrella Review of Self-Care Instructions and Evidence-Based Recommendations

The present umbrella review aimed to characterize periodontal self-care instructions, prescriptions, and motivational methods; evaluate the associated periodontal outcomes; and provide integrated, evidence-based recommendations for periodontal self-care in periodontally healthy orthodontic patients with fixed appliances. The presently applied study protocol was developed in advance, compliant with the PRISMA statement, and registered on PROSPERO (CRD42022367204). Systematic reviews published in English without date restrictions were electronically searched until 21 November 2022 across the PROSPERO Register and Cochrane Library, Web of Science (Core Collection), Scopus, and MED-LINE/PubMed databases. The study quality assessment was conducted through the AMSTAR 2 tool. Seventeen systematic reviews were included. Powered and manual toothbrushes showed no significant differences in biofilm accumulation, although some evidence revealed significant improvements in inflammatory, bleeding, and periodontal pocket depth values in the short term with powered toothbrushes. Chlorhexidine mouthwashes, but no gels, varnishes, or pastes, controlled better biofilm accumulation and gingival inflammation as adjuncts to toothbrushing, although only for a limited period. Organic products, such as aloe vera and chamomile, proved their antimicrobial properties, and herbal-based mouthwashes seemed comparable to CHX without its side effects. Motivational methods also showed beneficial effects on periodontal biofilm control and inflammation, while no evidence supported probiotics administration.

Patients' awareness regarding the quality of their oral hygiene: development and validation of a new measurement instrument

BACKGROUND

The present research aimed to develop and validate a standardised survey instrument for the assessment of patients' awareness of the quality of their oral hygiene performance.

METHODS

A digital questionnaire was developed that assesses both patients' naïve self-perceptions of oral cleanliness (SPOCn) after tooth brushing and patients' perceptions after being informed how oral cleanliness may be captured in dentistry (SPOCd). Three studies (N = 56 adults, N = 66 adolescents and one of their parents, N = 24 university students) assessed the instrument's feasibility (patient reports), reliability (internal consistency), validity (correlation with other constructs; sensitivity to manipulation of actual tooth brushing), and the correlation with actual oral cleanliness after tooth brushing.

RESULTS

All study groups accepted the questionnaire well; average answering times were less than 5 min. Cronbach's α exceeds 0.90; correlational analyses support the discriminant validity regarding oral hygiene related self-efficacy expectations and stages of change; manipulation of oral hygiene behaviour results in the expected changes of SPOC scores. Patients' SPOC correlate only moderately with actual oral cleanliness. The comparison between SPOCd scores and actual oral cleanliness indicate that they considerably overestimate their oral hygiene performance.

CONCLUSIONS

The SPOC questionnaire is an easy-to-use, well-accepted, reliable and valid instrument for the assessment of patients' awareness of the quality of their oral hygiene for research and clinical purposes. The results of the questionnaire may help to reveal unrealistic self-perceptions of patients regarding their oral hygiene. It can raise their awareness of the need to improve their skills and/or efforts in this regard. Trial registration The third study was an interventional study and was registered in the appropriate national register ( www.drks.de ; ID: DRKS00018781; date of registration: 12/09/2019).

Good role models? Tooth brushing capabilities of parents: a video observation study

BACKGROUND

Research in adolescents reveals that they are not capable to remove dental plaque effectively. Inconsistent application of brushing techniques and neglect of certain areas while brushing are very common. As parents play a major role in the oral health education, the present study aimed to examine and describe the tooth brushing performance of the parents of adolescents.

METHODS

Parents of adolescents (N = 66) were asked to perform oral hygiene to the best of their capabilities in front of a video camera and dental plaque was recorded before and afterwards. Papillary bleeding was also assessed.

RESULTS

The tooth contact time (i.e. net brushing duration) averaged 155 s ± 58 s. Gingival margins showed persistent plaque at 68% ± 14% of the sections assessed. Papillary bleeding was found at 52% ± 18% of the papillae. Parents brushed inner surfaces lesser than the outer surfaces (41 s ± 24 s vs. 73 s ± 33 s) and 29% of the parents completely missed the inner surfaces of at least one sextant. On the outer surfaces parents predominantly applied circular movements (66% ± 25% of brushing time). Vertical brushing prevailed on the inner surfaces (52% ± 30%). However, horizontal scrubbing was also very common (46% ± 31%).

CONCLUSIONS

Parents' tooth brushing performance was neither effective in terms of plaque removal nor did they fully comply with tooth brushing recommendations such as considering all inner surfaces when brushing or application of other than horizontal movements to lateral surfaces. Regarding oral hygiene, parents should not only be a good role model in terms of timing, frequency and duration of tooth brushing but should also be able to demonstrate how to brush teeth completely and effectively. The current research indicates that they might lack the latter skill.

Influence of teeth anatomical characteristics on the efficacy of manual toothbrushing manoeuvres

Purpose

The aim of the study was to investigate the efficacy of two toothbrushing techniques on the amount of plaque accumulation and to evaluate how the changes were correlated to the anatomical characteristics of the anterior maxillary arch.

Methods

Thirty subjects of both genders were included, they were asked not to brush for 12 h. Afterwards, they were asked to manually brush the left side of their maxillary arch with the modified Bass technique and the right side adopting the roll technique. The comparison of photographs taken before and after the manoeuvres, using a plaque disclosing agent, allowed the researchers to measure the changes in plaque accumulation measured using the Quigley and Hein plaque scoring classification. Linear regression analysis was used to evaluate the correlation between such changes and the teeth and arch anatomical characteristics.

Results

A mean reduction of 9.6 ± 5.2% considering both arches after brushing was observed. The changes in plaque accumulation were not different between the two techniques. The length of the line obtained joining the contact point between the central incisors and the contact point between the second premolar and the first molar on the left side and the distance between that line and the lateral incisor on the same side positively correlated to the decrease in the plaque scores (P = 0.046 and P = 0.044, respectively).

Conclusion

Both tested techniques were effective in plaque removal in the anterior maxillary arches. However, the research for the anatomical factors influencing the amount of efficacy of the toothbrushing manoeuvres was inconclusive. We can hypothesise that the adoption of one adequate technique could be more important than the teeth characteristics.

In Vivo Effects of a Hydroxyapatite-Based Oral Care Gel on the Calcium and Phosphorus Levels of Dental Plaque

OBJECTIVES

 Particulate hydroxyapatite (HAP; Ca5(PO4)3(OH)) is a biomimetic oral care ingredient. One mode of action in caries-susceptible individuals may be the adhesion/incorporation of HAP into dental plaque. Therefore, the aim of this in vivo study was to analyze the 3-day effects of a newly developed hydroxyapatite-based oral care gel on the calcium and phosphorus levels within the dental plaque of children.

MATERIALS AND METHODS

 This study was conducted in Kebon Padangan at Bali in Indonesia. Thirty-four children (mean age, 8.9 years; mean DMF-T [decayed, missing, and filled teeth; permanent teeth], 0.6; mean dmft-t [primary teeth] 4.5) were included in the study. The gel was applied thrice for 3 days by an experienced dentist. Dental plaque was collected at baseline and after the study. Levels of calcium and phosphorus of plaque samples were analyzed by energy-dispersive X-ray spectroscopy.

STATISTICAL ANALYSIS

 Medians for both calcium and phosphorus levels were calculated (baseline and 3-day application of HAP-gel).

RESULTS

 The calcium level increased after 3 days of application of the HAP-gel from 0.25 wt% (median) to 0.40 wt% (median), while the phosphorus level increased from 1.17 wt% (median) to 1.41 wt% (median). However, variations in both calcium and phosphorus levels measured in the pooled dental plaque samples were high.

CONCLUSION

 Within the limitations of the study, the 3-day application of the oral HAP-gel in children increased the median of both calcium and phosphorus levels in plaque. Consequently, a positive influence on the remineralization/demineralization process is very likely.

Oral cleanliness in daily users of powered vs. manual toothbrushes - a cross-sectional study

Background

Toothbrushing is a daily routine. Still, when adults are asked to manually perform oral hygiene to the best of their abilities, a considerable amount of plaque persists. Little is known about the performance of people who use a powered toothbrush. The present study thus analysed whether the capability to achieve oral cleanliness is better in people for whom powered toothbrushing is a daily routine.

Methods

University students, who either performed powered (N = 55) or manual (N = 60) toothbrushing for more than 6 months on a daily basis were asked to clean their teeth to the best of their abilities by their own device. Plaque was assessed prior to and immediately after brushing. Furthermore, gingival bleeding, recessions, periodontal pocket depths and dental status were assessed. Oral hygiene performance was video-taped and analyzed with respect to brushing duration, sites of brushing and application of interproximal cleaning devices.

Results

No differences between groups were found with respect to plaque before and after brushing, clinical parameters and overall brushing duration (all p > 0.05, all d < 0.156). After brushing, plaque persisted at approximately 40% of the sections adjacent to the gingival margin in both groups.

Conclusions

No advantage of daily powered toothbrushing as compared to daily manual toothbrushing was seen with respect to oral hygiene or clinical parameters. The capability to achieve oral cleanliness was low, irrespective of the type of toothbrush under consideration. Additional effort is thus needed to improve this capability.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0790-9) contains supplementary material, which is available to authorized users.

High Plaque Levels after Thorough Toothbrushing: What Impedes Efficacy?

OBJECTIVES

Previous studies have shown high levels of dental plaque after toothbrushing and poor toothbrushing performance. There is a lack of evidence about what oral hygiene behavior predicts persistent plaque. The present cross-sectional study thus relates toothbrushing behavior to oral cleanliness after brushing and to gingivitis.

METHODS

All young adults from a central town in Germany who turned 18 y old in the year prior to the examination were invited to participate in the study. They were asked to clean their teeth to their best abilities while being filmed. Videos were analyzed regarding brushing movements (vertical, circular, horizontal, modified Bass technique) and evenness of distribution of brushing time across vestibular (labial/buccal) and palatinal (lingual/palatinal) surfaces. Dental status, gingival bleeding, and oral cleanliness after oral hygiene were assessed.

RESULTS

Ninety-eight young adults participated in the study. Gingival margins showed persistent plaque at 69.48% ± 12.31% sites (mean ± SD) after participants brushed to their best abilities. Regression analyses with the brushing movements and evenness of distribution of brushing time as predictors explained 15.2% (adjusted R² = 0.152, P = 0.001) of the variance in marginal plaque and 19.4% (adjusted R² = 0.194, P < 0.001) of the variance in bleeding. Evenness of distribution of brushing time was the most important behavioral predictor.

CONCLUSION

Even when asked to perform optimal oral hygiene, young German adults distributed their brushing time across surfaces unevenly. Compared with brushing movements, this factor turned out to be of more significance when explaining the variance of plaque and bleeding.

KNOWLEDGE TRANSFER STATEMENT

Results of this study can help clinicians and patients understand the meaning of specific behavioral aspects of toothbrushing for oral cleanliness and oral health.

Toothbrushing: to the best of one's abilities is possibly not good enough

BACKGROUND

Weaknesses in toothbrushing performance can be seen when young adults are instructed to perform habitual toothbrushing. Nothing is known about toothbrushing behavior when instructed to perform to the best abilities. The present study analyzes such behavior and compares it to habitual behavior.

METHODS

A random sample of N = 98 young adults born in 1995 was examined in 2014/2015.They were asked to perform oral hygiene to the best of their abilities in front of a camera. Videos were analyzed regarding details of brushing behavior. A quality index was developed which describes the extent of the neglect of brushing on palatinal and vestibular surfaces. Data were compared to those of an earlier study of young adults (born in 1992, examined in 2011, N = 101) who were asked to perform oral hygiene as they habitually do.

RESULTS

The 1995 cohort (best abilities) brushed their teeth significantly longer than the 1992 cohort (habitual brushing). This was due to significant longer brushing at vestibular and occlusal surfaces. Neglect of palatinal surfaces was similar in both cohorts. Groups did not differ regarding brushing movements. 40% of the brushing time on lateral surfaces was spent with scrubbing movements despite opposing advice in common oral hygiene instructions.

CONCLUSIONS

Toothbrushing to the best of one's abilities might still not be good enough. Young adults apparently lack a reasonable concept of what is meant by high quality toothbrushing. More efforts should thus be undertaken to explain them (and adults) this concept.