Efficiency of Professional Tooth Brushing before

Shah RA et al: Ultrasonic Scaling Before Tooth Brushing
Efficiency of Professional Tooth Brushing
before Ultrasonic Scaling
Riddhi Anil Shah1, Bonny K Patel2
1,2- Karnavati School of Dentistry, Gandhinagar, Gujrat, India
Correspondence to:
Dr. Riddhi Anil Shah, Karnavati School of Dentistry, Gandhinagar,
Gujrat, India.
Regular dental check-ups and routine scaling are recommended to prevent periodontal diseases and to maintain oral
health. For the removal of dental plaque which usually remains even after careful tooth brushing and flossing, teeth
cleaning or prophylaxis is carried out. Tooth brushing is also an effective way for the routine cleansing of the teeth but
sometimes food debris are not removed especially in areas which are not accessible to normal tooth brushes.
Professional tooth brushing includes the use of electric toothbrushes, interdental brushes, and dental floss. The present
review throws a light on the general features of these three aids and also discusses the effectiveness of electric
toothbrushes, interdental brushes, and dental floss prior to ultrasonic scaling.
KEYWORDS: Dental Floss; Tooth Brushing; Ultrasonic Scaling
procedure for the removal of tartar (mineralized plaque)
that may develop in areas that are difficult to clean by
routine tooth brushing. It is often done by a dental
Teeth cleaning are a part of oral hygiene and involve the
hygienist and includes tooth scaling and tooth polishing
removal of dental plaque from teeth with the intention of
and debridement if too much tartar has accumulated. This
preventing cavities (dental caries), gingivitis, and
involves the use of various instruments or devices to
periodontal disease. Deposits on the teeth can be removed
loosen and remove deposits from the teeth. As far as
by two ways. Either the people can clean it by themselves
frequency of cleaning is concerned, research on this
with the use of tooth brushes and interdental cleaning
matter is still inconclusive. That is, it has neither been
agents but sometimes they become hard or mineralized
shown that more frequent cleaning leads to better
(tartar). In such situations dental professionals can help in
outcomes nor that it does not. A review of the research
removing the deposits which are not removed by routine
literature on the question concluded "the research
cleaning. Plaque is a bio-film which is formed by the
evidence is not of sufficient quality to reach any
colonies of bacteria that live in our mouth. Acid produced
conclusions regarding the beneficial and adverse effects
by the plaque bacteria is destructive to our teeth and
of routine scaling and polishing for periodontal health
gums. Calculus or tartar forms when plaque is not
and regarding the effects of providing this intervention at
properly removed and the bacterial colonies calcify and
different time intervals".1,3 This conclusion was
mineralize into a hard substance, which then attracts more
reaffirmed when the 2005 review was updated in 2007.4
harmful bacteria. Gingivitis is a gum disease which is
Thus, any general recommendation for a frequency of
caused by the active and destructive bacteria. Our gums
routine cleaning (e.g. every six months, every year) has
become inflamed, swell and redden in response to the
no empirical basis. Moreover, as economists have pointed
infection and to prevent advancement to periodontal
out, dentists (or other dental professionals) have an
disease, this condition must be aggressively treated.
incentive to recommend frequent cleaning because it
Blood on the toothbrush or when rinsing after brushing is
increases their revenues. Most dental hygienists
a sign of gingivitis. Periodontal disease i.e. Periodontitis,
recommend having the teeth professionally cleaned every
if left untreated can cause so much bone loss that our
six months. More frequent cleaning and examination may
teeth become loose and may exfoliate. Periodontal
be necessary during treatment of dental and other oral
disease can be diagnosed by measuring the depth of the
disorders. Routine examination of the teeth is
pockets, checking for bleeding sites, and by assessing
recommended at least every year. This may include
bone loss through digital x-rays and clinical observation.
yearly radiographic examination. 1
Though periodontal disease is irreversible but it can be
managed by dental professionals. Pockets are the sites
where bacteria can colonize and ultimately can lead to
loss of attachment and hence periodontitis.2
Regular dental check-ups and routine scaling are
recommended to prevent periodontal diseases and to
maintain oral health.5 However, dental treatment
A tooth cleaning (preventive treatment) is basically a
How to cite this article:
Shah RA, Patel BK. Efficiency of Professional Tooth Brushing before Ultrasonic Scaling. Int J Dent Med Res 2015;1(6):202-205.
Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6
Shah RA et al: Ultrasonic Scaling Before Tooth Brushing
generates different types of anxiety among dental
patients. Patients are reluctant to receive scaling,
particularly because of hypersensitivity, noise and
discomfort in the mouth from the water coolant, among
other reasons.6,7 Tooth hypersensitivity, which commonly
occurs during the ultrasonic scaling procedure, may result
from tooth problems, including the exposure of root or
dentin. Hypersensitivity may also occur because of an
excessive number of scaling procedures and the operation
of the ultrasonic scaler on the tooth surface with improper
tip angulations.8 Using an ultrasonic scaler reduces
treatment times by allowing a shorter amount of time to
remove the dental plaque biofilm and dental calculus
compared with using manual periodontal instruments.
Moreover, the scaler relieves clinician fatigue and easily
reduces subgingival micro- flora.8
However, an ultrasonic scaler causes patient discomfort
because of pain, vibration, noise and a large volume of
water coolant; excessive operation of the instrument may
also prove to be detrimental to periodontal health by
roughening the root surface.8,9 Although routine scaling is
a cost-effective method of preventing periodontal
diseases and dental caries, various burdens of scaling
impede patients from undergoing scaling.6,10 The usage
rate of periodontal scaling among dental patients is
particularly low. Thus, various measures must be devised
to reduce patient burden by incorporating easier and safer
scaling procedures.6,7,11
During tooth brushing the mechanical removal of dental
plaque is achieved mainly because of direct contact of
bristles with the teeth and the scouring action of bristles
across tooth and gum surfaces. Reaching an optimal level
of supragingival plaque control is one of the treatment
goals for establishing a healthy periodontium.12 The
effectiveness of certain electric toothbrushes in reducing
signs of gingival inflammation has been proven in
numerous studies over the past decade.13,14 Recently a
variety of electric toothbrushes have been developed to
improve the efficiency of plaque removal using increased
bristles velocity, brush stroke frequency and various
bristle patterns and motions.12 These designs including
rotary, oscillating/rotating with pulsation and brush heads
which move at high frequencies, have shown in
controlled clinical studies to be more effective in
removing plaque and stain in a shorter time than that
which is achieved with a standard manual brush.15,16
Also, some modern electric brushes appear to remove
plaque from approximal surfaces significantly more
effectively than conventional manual brushes.17 Studies12
have shown that use of tooth brushes before ultrasonic
scaling helps in reducing the time of ultrasonic device
Today the general community is becoming more aware
Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6
about the importance of plaque removal for the
prevention of dental and systemic diseases. However,
daily habits such as interproximal plaque removal have
yet to be followed by many people. Though routine tooth
brushes can remove deposits from various tooth surfaces
but they are not much effective interproximally. Dental
floss, which is quite effective for interproximal plaque
removal, is not much used by the majority of the
population on a regular basis. Therefore, other
alternatives should be investigated so as to maintain
lower interproximal plaque levels.18
Interdental brushes can serve as a better alternative to
flossing and can be used daily for lowering the
interproximal plaque levels. They are more effective than
dental floss. The effectiveness of Interdental brushes
further depend on their size, shape as well as the surfaces
of the teeth. Other considerations include an individual's
manual dexterity, how easy and fast a product is to use,
and an individual's motivational level.18
In a study conducted for investigating the effectiveness
of manual devices (specifically that of TePe Interdental
Brushes and Ultra Floss) in comparison to that of a
mechanically automated Interclean Interdental Plaque
Remover (Oral-B Braun), it was found that while both the
devices decreased the amount of plaque interproximally,
manual devices were more effective in reducing the
interproximal plaque and bleeding, and interdental
brushes were better accepted by the study population.19
Five different TePe interdental brush sizes were used
during the investigation, which alludes to the importance
of having access to multiple sizes of interdental brushes.
Different sizes allow for access to different sites within
the mouth. For healthy gingiva and smaller embrasures,
the smallest interdental brushes are more effective and
relevant. As proved by this study the use of interdental
brushes on a daily basis give the best results. So this
study basically supports the daily use of manual
devices.18,19 However, as mentioned, motivation is also an
important key to effectiveness.18
In comparison to simple brushing both the manual
devices i.e. floss and interdental brushes are more useful
in removing plaque from the interproximal area.20 A
study was conducted which compared the efficacy of
floss and interdental brushes. In this study one-month
time period was given from the initial visit and data
collection. At the one-month mark, it was determined that
the mean difference for supragingival plaque for
interdental brushes was 58.43 and 50.21 for flossing
indicating that interdental brushes are more effective in
interproximal plaque removal than the dental floss.20
Dental floss is a cord of thin filaments used to remove
food and dental plaque from between teeth. The floss is
gently inserted between the teeth and wiped along the
teeth sides, especially close to the gums or underneath
them. Toothbrushes do not clean between teeth or below
the gum line. Used as an addition to tooth brushing as
Shah RA et al: Ultrasonic Scaling Before Tooth Brushing
part of regular oral hygiene flossing can reduce gingivitis
and halitosis compared to tooth brushing alone. In
dentistry, floss is classed as an interdental (between teeth)
cleaning aid. According to the American Dental
Association, flossing in combination with tooth brushing
can help prevent gum disease and halitosis.21 A 2012
review of trials concluded that flossing in addition to
tooth brushing reduces gingivitis compared to tooth
brushing alone. In this review, researchers found "some
evidence from twelve studies that flossing in addition to
tooth brushing reduces gingivitis compared to tooth
brushing alone" but only discovered "weak, very
unreliable evidence from 10 studies that flossing plus
tooth brushing may be associated with a small reduction
in plaque at 1 and 3 months." 22,23 A 2008 systematic
review of 11 studies concluded that adjunctive flossing
was no more effective than tooth brushing alone in
reducing plaque or gingivitis.24 It has been suggested that
these outcomes are caused by the rarity of proper flossing
technique,25 although two studies found no effect of floss
even among dental students.24 One review reported that
professional flossing of children reduced dental caries
risk, but self-flossing did not.26
Although flossing is commonly used as a means of
disrupting the oral biofilm between the teeth and
therefore preventing gingival disease (gingivitis,
periodontitis, etc.), its effectiveness is determined by the
clients preference, technique and motivation to floss
Flossing has been considered a more difficult method of
interdental cleaning than using an interdental brush.
Interdental brushes are said to be preferred due to their
one-handed method of use and time efficiency compared
to flossing.27
According to Berchier et al. (2008) "The dental
professional should determine, on an individual patient
basis, whether high-quality flossing is an achievable
goal." Berchier et al. (2008) also state that "routine
instruction of flossing in gingivitis patients as helpful
adjunct therapy is not supported by scientific evidence.”24
Thus, from the present review article we can conclude
that minimizing the dental scaling procedure by
professional brushing before scaling will shorten the
treatment time and resolve client discomforts, such as
potential dental injury and noise, allowing minimal use of
ultrasonic devices. A toothbrush is a proper instrument to
remove dental plaque biofilm on the tooth surface;
however, clinicians rarely use it during dental practice.
The present review indicates the effective use of a
toothbrush in the dental clinic. It is advised that methods
should be devised to boost subject satisfaction and
shorten the treatment time by changing the dental scaling
Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6
Bader J. Insufficient evidence to understand effect of
routine scaling and polishing. Evid Based Dent 2005;6:5-6.
Beirne PV, Worthington HV, Clarkson JE. Beirne PV, ed.
Cochrane Database of Systematic Reviews. Cochrane
Database Syst Rev 2007;4:CD004625.
Darby ML. Dental Hygiene: Theory and Practice.
Missouri:Saunders 2010.
Milgrom P, Newton JT, Boyle C, Heaton LJ, Donaldson N.
The effects of dental anxiety and irregular attendance on
referral for dental treatment under sedation within the
National Health Service in London. Commun Dent Oral
Epidemiol 2010;38:453-59.
Cheon SY, Won BY. Affecting factors to oral scaling
experience of the partworker. J Korean Acad Dent Hygiene
Edu 2011;11:1-11.
Arabaci T, Cicek Y, Canakci CF. Sonic and ultrasonic
scalers in periodontal treatment: a review. Int J Dental
Hygiene 2007; 5: 2–12.
Dahiya P, Kamal R, Gupta R, Pandit N. Comparative
evaluation of hand and power-driven instruments on root
surface characteristics: a scanning electron microscopy
study. Contemp Clin Dent 2011;2:79-83.
Noh HJ, Park SY. Cost-Benefit Analysis of periodontal
disease prevention. Focus Prev Scaling 2002;27:50-65.
Kim MJ, Noh H, Oh HY. Efficiency of professional tooth
brushing before ultrasonic scaling. Int J Dent Hygien
Van der Weijden GA, Timmerman MF, Piscaer M,
IJzerman Y, Van der Velden U. Plaque removal by
professional electric toothbrushing compared with
professional polishing. J Clin Periodontol 2004;31:903-7.
Walmsley AD. The electric toothbrush, a review. Br Dent J
Van der Weijden, GA, Timmerman MF, Danser MM, Van
der Velden U. The role of electric toothbrushes:
advantages and limitations. In: Proceedings of the
European workshop on Mechanical Plaque Control, eds.
Lang NP, Attström R, Löe H. London: Quintessence
Publishing Co., Ltd 1998, pp. 138-56.
Sharma NC, Galustians HJ, Qaqish J, Cugini M, Warren
PR. The effect of two power toothbrushes on calculus and
stain formation. Am J Dent 2002;15:71-6.
Heanu M, Deacon SA, Deery C, Robinson PG, Walmsley
AD, Worthington HV, Shaw WC. Manual vs powered
toothbrushing for oral health (Cochrane Review). The
Cochrane Library, Issue 1, Oxford: Update Software 2003.
Löe H. Oral hygiene in the prevention of caries and
periodontal disease. Int Dent J 2000;50:129-39.
Esteves I. The effectiveness of interdental brushes.
Schmage P, Platzer U, Nergiz I. Comparison between
manual and mechanical methods of interproximal hygiene.
Quintessence Int 1999;30:535-39.
Noorlin I, Watts TL. A Comparison of the Efficacy and
Ease of Use of Dental Floss and Interproximal Brushes in a
Randomised Split Mouth Trial Incorporating an
Assessment of Subgingival Plaque. Oral Health Prev Dent
21. http://en.wikipedia.org/wiki/Dental_floss.
22. Sambunjak D, Nickerson JW, Poklepovic T, Johnson TM,
Imai P, Tugwell P, Worthington HV. Flossing for the
Shah RA et al: Ultrasonic Scaling Before Tooth Brushing
management of periodontal diseases and dental caries in
adults. Cochrane Database Syst Rev 2011;7:CD008829.
23. Matthews D. Weak, unreliable evidence suggests flossing
plus toothbrushing may be associated with a small
reduction in plaque. Evid Based Dent 2012;13:5-6.
24. 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 Den Hyg 2008;6:265-79.
25. Winterfeld T, Schlueter N, Harnacke D, Illig J, MargrafStiksrud J, Deinzer R, Ganss C. Toothbrushing and
flossing behaviour in young adults—a video observation.
Clin Oral Investig 2014 Sep 4. [Epub ahead of print].
Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6
26. Hujoel PP, Cunha-Cruz J, Banting DW, Loesche WJ.
Dental flossing and interproximal caries: a systematic
review. J Dent Res 2006;85:298-305.
27. Imal P, Yu X, MacDonald D. Comparison of interdental
brush to dental floss for reduction of clinical parameters of
periodontal disease: A systematic review. Can J Dent Hyg
28. Bergenholtz A., Brtthon J. Plaque removal by dental floss
or toothpicks: An intra-individual comparative study. J
Clin Periodontol 1980;7:516-24.
Source of Support: Nil
Conflict of Interest: Nil
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