Effectiveness of a single-tuft toothbrush for control of newly formed

Original Article
Braz J Oral Sci.
April | June 2016 - Volume 15, Number 2
Effectiveness of a single-tuft toothbrush for
control of newly formed dental biofilm
Iohana Hasegawa1, Camila Veríssimo1, Victor Angelo Montalli1, Marcelo Sperandio1, Daiane Cristina Peruzzo1
São Leopoldo Mandic – SLMANDIC, São Leopoldo Mandic Dental School and Research Institute, Department of Oral Pathology, Campinas, SP, Brazil
Aim: To compare the effectiveness of a single-tuft toothbrush (STB) with conventional toothbrushes
(CT) to control dental biofilm neoformation in the dentogingival area. Methods: For this cross-sectional
prospective blind study, 20 periodontally healthy subjects were selected and randomly divided into 4
groups: STB; CT; CHX - chlorhexidine mouthwash (positive control) and PS - placebo mouthwash
(negative control). The subjects were instructed to use only the assigned care method for 72 h
with a 7-day washout period between experiments. The evaluated parameters were visible and
disclosed plaque indices (PI and DPI), gingival bleeding index (GBI) at baseline (T-0) and at the end
of each experimental period (T-72). Results: Data analysis demonstrated that at T-0 no difference
was observed for any of the parameters (p>0.05); after 72 h, CT, STB and CHX showed equivalent
effectiveness at controlling biofilm. When the PI data were analyzed, between T-0 and T-72, STB
was similar to CT and CHX (p<0.05), whereas for DPI, STB was significantly superior to the other
methods. Except for PS, all methods yielded similar results for GBI (p<0.05). Conclusions: The tested
STB was effective at controlling short-term dental biofilm neoformation on the dentogingival area.
Keywords: Dental Plaque. Biofilms. Oral Hygiene.
Received for publication: July 19, 2016
Accepted: November 16, 2016
Correspondence to:
Daiane C. Peruzzo
São Leopoldo Mandic Institute and Research Center
Rua José Rocha Junqueira 13, Ponte Preta,
CEP: 13045-755 - Campinas SP Brasil
Phone: +55 19 3211 3659 - Fax: +55 19 3211 3635
E-mail: daiaperuzzo@yahoo.com.br
Gingivitis is primarily caused by dental biofilm, which must be controlled in
order to achieve and maintain periodontal health1. The bacteria in biofilm are mostly
in balance with the host, which denotes a state of persistent periodontal health. When
such homeostasis is broken due to inadequate oral hygiene, gingivitis settles in, which
may progress into periodontitis2. From the pathophysiological viewpoint, no individual
is immune to gingivitis, provided biofilm is allowed to accumulate over time, breaking
the gingival homeostasis.
When intrasulcular homeostasis is broken, visible clinical changes begin to emerge,
such as spontaneous gingival bleeding, bleeding on brushing, erythema, swelling and
changes in gingival texture2,3. It is therefore paramount to concentrate efforts at tackling
the root of the problem using methods of oral hygiene and consequently halting dental
biofilm formation4. The gold standard for prevention of gingivitis is mechanical removal
of biofilm by regular toothbrushing4-6. For hygiene to be performed according to the
instructions by dental professionals, biofilm control strategies must be tailored to the
needs of each individual.
Toothbrush and toothpaste are undoubtedly the most widespread tools for
mechanical removal of plaque and debris from the tooth surface. Thus, to meet specific
individual needs several devices were developed, for instance, interdental brushes and
dental floss for interdental areas, and single-tuft brushes, for intra-sulcular and even
buccal/lingual/palatal areas7-10.
In normal circumstances, teeth cleaning solely with a conventional toothbrush
will not remove biofilm equally from all surfaces11. Complementation is therefore
Braz J Oral Sci. 15(2):113-118
Effectiveness of a single-tuft toothbrush for control of newly formed dental biofilm
required using auxiliary devices, such as dental floss or tape,
interproximal brushes and/or single-tuft brushes, according to
the shape, size and access to the cleaned site. Single-tuft brushes
are delicate and may be advised for specific areas. Usually, they
are recommended for difficult to access sites, such as furcations,
distal surfaces of molars, areas of amputated roots, buccal or
lingual surfaces with irregular gingival margin, crowded areas
and proximal surfaces of isolated teeth12. Additionally, because
it is relatively uncomplicated to direct STB towards the gingival
sulcus, they may be the most effective method to remove biofilm
from deep pockets.
The flowchart of evidence on the role of supragingival
bacterial biofilm is complete when biofilm control leads to
gingival health1. Evidence derived from large cohort studies have
demonstrated that high standards of oral hygiene will ensure
stability of the periodontium13. Both short-term and long-term
cross-sectional as well as longitudinal studies have shown that
the incidence of gingivitis and biofilm accumulation still seems
to be high even among the adult population that brush their teeth
Despite STB being highly recommended by periodontal
specialists, there are few studies 15-17 demonstrating the
effectiveness of such tools at controlling dental biofilm at
crevicular sites. The aim of this study was to compare the
effectiveness of single-tuft brushes against the gold standard,
namely conventional toothbrushes, at controlling newly formed
biofilm at the dentogingival area of healthy individuals.
Material and methods
Sample selection
This study was approved by the Ethics Committee of the
São Leopoldo Mandic Dental School, Campinas / SP, protocol
#356827/2013. Sample size was based on previously published
studies of similar design18,19 and consisted of 20 dental students
from the São Leopoldo Mandic Dental School.
The inclusion criteria were: systemically and periodontally
healthy subjects (probing depth ≤ 3mm and no gingival
bleeding)20-21, aged between 18 and 30 years with a minimum of 20
remaining teeth, who agreed to participate in the study. Exclusion
criteria were: presence of cervical restorations, antimicrobial
therapy for any medical or dental condition within 6 months
prior to the trial, use of drugs known to affect the periodontal
environment (anti-inflammatories, pain-killers, contraceptives,
anticonvulsants, immunosuppressants, cyclosporin, anticoagulants
and calcium channel blockers) also within 6 months prior to
the baseline periodontal examination, orthodontic treatment or
devices, pregnant women and breastfeeding mothers.
Study design
Two types of toothbrushes were compared: a single-tuft
brush (Bitufo® - Hypermarcas, Senador Canedo - GO, Brazil)
and a conventional toothbrush (Bitufo® - Hypermarcas, Senador
Canedo - GO, Brazil). 0.12% chlorhexidine mouthwash (Bitufo®,
Braz J Oral Sci. 15(2):113-118
Senador Canedo - GO, Brazil) was used every 12 h as a positive
control, whereas a placebo solution (Bitufo®- Hypermarcas,
Senador Canedo - GO, Brazil) with similar features as the
chlorhexidine mouthwash, but without the active ingredient, was
used as a negative control. The groups were defined as follows:
STB – single-tuft brushes (test), n=20; CT - conventional
toothbrush (gold standard), n=20; CHX - chlorhexidine
mouthwash (0.12% - positive control), n=20; and PS - placebo
solution (negative control), n=20. During each experimental
phase, the subjects were instructed to use solely the method
designated to their group, excluding any other additional cleaning
strategy. Each experimental phase lasted 72 h with a 7-day
washout period in between, in order to avoid a possible residual
(carryover) effect of the previous treatment method. During this
washout period, all volunteers used a standard toothbrush and
toothpaste provided by the researchers.
The mouthwash solutions were packed and coded in order
to prevent identification of the used product. The codes were
revealed only when the study was complete.
Clinical Experimental Phase
Following patient selection, a clinical oral examination was
performed by a single examiner (IH), trained and calibrated to
obtain the following initial clinical parameters: visible plaque
index (PI), disclosed plaque index (DPI) and gingival bleeding
index (GBI), according to Ainamo and Bay22, as shown in Figure
1 (A, B and C, respectively). In addition, periodontal evaluation
was performed, which included probing depth (PD), gingival
recession and clinical attachment level, in order to assure absence
of gingivitis clinically. Subsequently, professional biofilm
removal was performed on each volunteer using a rubber cup
and prophylaxis paste. Personalized instructions for toothbrushing
were given individually and verbally by another researcher (CV),
according to brush (conventional and STB) and solution (placebo
and chlorhexidine). Only during the washout period were the
subjects encouraged to apply other conventional oral hygiene
methods, such as dental floss or tape.
Following the trial phase, a second professional prophylaxis
session was performed. The volunteers were then randomly
assigned (using a computer list) to their respective sequence of
oral hygiene methods, observing the 7-day washout period20. PI,
DPI and GBI were recorded both at the beginning and at the end
of each trial period.
Statistical Analysis
Only the subjects who completed the study (n=18) were
considered for statistical purposes. Prior to the analysis, the
Kolmogorov-Smirnov test was applied to assess normality. For
intra-group analysis (between periods) of the data (PI, DPI and
GBI), Student’s t test was used. For inter-group analysis (between
treatments), ANOVA/Tukey tests were applied. BioEstat 5.0
(Sustainable Mamirauá Institute, Belém, PA, Brazil) software was
used for statistical calculations. For all analyzes, the significance
level was set at 5%.
Effectiveness of a single-tuft toothbrush for control of newly formed dental biofilm
Fig.2. Mean (±SD) for the clinical parameters at baseline (T-0) (A), and after 72 h (B)
for single-tuft brush (STB), conventional toothbrush (CT), chlorhexidine (CHX) and
placebo solution (SP).
* indicate significant intragroup differences for the clinical parameters evaluated, by
Anova and Tukey test (p <0.05).
In the intra-group comparison between T-0 and T-72,
the percentage of accumulated visible plaque (PI) (Figure 3)
increased significantly only in the PS group (p<0.05). As
shown in Figure 4, assessing the percentage of disclosed plaque
(DPI), a significant difference was observed in CT, CHX and
PS, while the STB group showed similar results between T-0
and T-72 (p<0.005).
Fig.1. Intra-oral examination for the following clinical parameters: (A) visible Plaque
Index (PI); (B) Disclosed Plaque Index (DPI), and (C) Gingival Bleeding Index (GBI).
Twenty volunteers were selected from March to June 2013.
The participants were aged between 18 and 30 years (mean age
21.1 years), 13 females and 7 males. Among the 20 initially
selected individuals , 18 completed the study and two were lost
to follow-up.
Intergroup analysis at the early experimental stage (T-0)
revealed no statistically significant difference between treatments
(STB, CT, CHX, PS) for any of the evaluated parameters (PI,
DPI, GBI), demonstrating homogeneity between the groups
(Figure 2A). After 72 h (T-72) (Figure 2B), a significant
difference was observed (p<0.05) only for PS in terms of PI
and DPI, but not GBI.
Fig.3. Mean (±SD) for visible Plaque Index (PI), for the treatments, at baseline (T-0) and
after 72 h (T-72) to single-tuft brush (STB), conventional toothbrush (CT), chlorhexidine
(CHX) and placebo solution (SP).
Different lowercase letters indicate significant intragroup differences over time, by
Student t test (p<0.05).
Regarding GBI (Figure 5), no significant differences were
observed between T-0 and T-72 for all treatments.
Braz J Oral Sci. 15(2):113-118
Effectiveness of a single-tuft toothbrush for control of newly formed dental biofilm
Fig.4. Mean (±SD) Disclosed Plaque Index (DPI) for the treatments at baseline (T-0) and
after 72 h (T-72) for single-tuft brush (STB), conventional toothbrush (CT), chlorhexidine
(CHX) and placebo solution (SP).
Different lowercase letters indicate significant intragroup differences over time, by
Student t test (p<0.05).
Fig.5. Mean (±SD) Gingival Bleeding Scores (DPI) for the treatments at baseline
(T-0) and after 72 h (T-72) to single-tuft brush (STB), conventional toothbrush (CT),
chlorexidine (CHX) and placebo solution (SP).
Different lowercase letters indicate significant intragroup differences over time, by
Student t test (p<0.05).
Faced with the limitations of conventional hygiene methods,
new types of brushes have been developed, including electric
toothbrushes, single-tuft and interdental brushes7,8,23. Tooth
brushing per se is often insufficient to remove dental biofilm,
particularly from interproximal and dentogingival areas. In turn,
such scenario will demand complementary strategies to tackle
biofilm disruption, including the use of dental floss/tape, interdental
brushes, mouthwashes, etc. Only a handful of methodologically
sound studies have focused on the effectiveness of such methods,
especially in the intra-sulcular area. In this context, the present
cross-sectional and prospective study aimed to evaluate the
effectiveness of single-tuft brushes to control the new formation
of bacterial biofilm at this particular site.
The methodological design of the present study allowed for
testing all volunteers for all evaluated methods, thus reducing
possible biases. Additionally, the inclusion of washout periods
minimized the residual effects of the methods used before each new
treatment24-26. Such study design may counterbalance carryover
interferences and provide an estimate of treatment effect with
Braz J Oral Sci. 15(2):113-118
minimal increase in variance, even if carryover is included in
the model.
At baseline (T-0), no difference was observed between
treatments for any of the parameters evaluated, demonstrating
sample homogeneity between groups. At T-72, however,
differences were observed in the placebo group for PI, DPI, but
not for the GBI. These results reflect the relatively low hygiene
withdrawal period in this sample of periodontally healthy
individuals. At 72 h, no clinically evident signs of gingival
inflammation could be detected3,27, corroborated in the present
study by the GBI values.
Additionally, scanning electron microscopy studies
evaluating the initial stages of supragingival plaque formation
confirmed the presence of a microbial deposit-free zone located
between the biofilm layer and the gingival margin28. Bergström29
and Quirynen and coworkers30, when analyzing the initial stages
of biofilm formation by sequential photographic records registered
clinically this event. In their study, the biofilm-free zone was not
stained by plaque-disclosing solutions. Subsequently, studies
have shown that a supragingival plaque-free zone persists for up
to 96 h31,32.
In this study, both disclosed and visible plaque indices
were used to assess plaque scores and biofilm new formation.
Visible plaque index (PI) was used to demonstrate gross plaque
accumulation, whereas DPI was used to detect low amounts of
plaque, as it is a much more sensitive method than PI. Although the
use of disclosing solutions in the management of biofilm control
can be somehow discouraging for some patients, when combined
with index scales, they enable comparisons between new and
existing oral hygiene products33. The choice for disclosing tablets
over disclosing solutions was based on the fact that the former
is widely used and is likely to be less disturbing of the biofilm,
since the latter involves mechanical application of the solution
with a cotton swab, which in turn may disrupt biofilm and risk
false negatives34.
When confronting the results between T-0 and T-72, only
the placebo solution showed a significant difference to PI. It
is important to stress again that this index requires a greater
accumulation of biofilm on the tooth surface for clinical detection.
As for DPI, greater biofilm accumulation for the conventional
brush, placebo solution and chlorhexidine solution groups was
present, which was not observed in the group that used the singletuft brush. This may reflect the macrostructural characteristics of
the single-tuft brush, which has a small head with bristles directed
towards the area to be cleaned and must necessarily be used on
a single surface of the tooth at a time, thus resulting in thorough,
slower and more rational brushing. These findings agree with those
by Ferraz et al.15, who compared mechanical biofilm control with
conventional and single-tuft brushes and concluded that the singletuft brush group had a lower PI than the conventional brush groups
after a 4-week period. The results obtained in the study by Lee and
Moon26, which evaluated the effectiveness of single-tuft brushes
on the buccal and lingual surfaces of molars also corroborate the
findings of the present study. They concluded that difficult access
areas could be best reached using this type of brush.
In the present study, chlorhexidine was used as a positive
control, as it is independent from an individual’s manual
Effectiveness of a single-tuft toothbrush for control of newly formed dental biofilm
dexterity and is regarded as a gold standard for chemical plaque
control due to its bactericidal and bacteriostatic properties35-37. A
concentration of 0.12% was selected based on a previous study38,
which demonstrated that a lower concentration of CHX was just
as effective at reducing gingivitis as the traditional 0.20%. Rinsing
is easier than either brushing or flossing and takes less time,
therefore requiring a shorter attention span. Patients also tend to
be more concerned with a ‘’fresh breath’’ than with plaque and
gingivitis levels; consequently, patient adherence to rinsing may
be higher in this case than to adequate brushing and flossing (or
other cleaning dispositive)39.
Rapp and coworkers 16 compared the Bass technique
(conventional brushes) using single-tuft brushes alone or in
combination with dental flossing in interproximal areas. Their
results showed that, histomorphometrically, the Bass technique
and the combination of single-tuft brushes with floss yielded very
similar results and slightly better than the Bass-floss combination,
while the use of single-tuft brushes without dental flossing showed
poorer results. The findings from Rapp et al.16 do not corroborate
those from the present study. It is important to highlight that their
analysis involved a histomorphometric evaluation of biopsies from
interproximal areas after 28 days. Such different methodological
approaches are not directly comparable and any loose parallels
can only be established based on extrapolation.
Franceschi and Oppeman17 evaluated the interproximal
cleaning capacity of dental flossing and toothpicking with that
of a single-tuft brush and found that both were able to maintain
adequate levels of hygiene and gingival health. Under special
circumstances, whenever the use of dental floss is not applicable,
other methods can be applied due to their popularity, which can
make plaque control more acceptable. As there was a combination
of single-tuft brushes with toothpicks, the effectiveness of the
former on its own cannot be verified, though it may be suggested
that their results corroborate those from the present study, since
the use of toothpicks alone is generally regarded as inefficient.
In a randomized, single-blinded, controlled clinical trial10
performed with orthodontic patients, subjects wearing lingual fixed
appliances were asked to brush with a triple head or an orthodontic
toothbrush alone for one month. Subsequently, they were instructed
to brush in conjunction with a single-tufted toothbrush for an
additional month. Their teeth were professionally cleaned at
baseline and one month later. Similarly to the present study, the
authors observed a positive effect of the single-tuft brush: when
used alone, the triple-headed toothbrush seemed to have removed
dental biofilm more effectively than the orthodontic toothbrush.
The addition of a single-tuft brush, however, eliminated differences
between groups.
As far as the authors are aware, there have only been a
few studies comparing single-tuft brushing with conventional
brushing at the dentogingival areas. Caution must be taken with
the interpretation of the results from this study, to prevent a hasty
notion that single-tuft brushes should be indicated as a sole method
for oral hygiene. The present study did not aim to directly influence
clinicians into recommending STB as a substitute to conventional
mechanical biofilm control methods. Additionally, Lee & Moon26
reported that participants in their study complained that using
single-tuft brushes was rather tiresome. Such drawbacks suggest
that single-tuft brushes should be used as an additional tool and
not as single method of oral hygiene. Some limitations of this
study include the short-term nature of the collected data, making
it difficult to forecast long-term results. In addition, the age of the
volunteers varied from 18 to 30 years, with occasional differences
in motivational levels and possible inherent differences in the
anatomy of their dentition, which may, to some extent, interfere
with the results. Longer follow-up studies should be performed to
evaluate the longitudinal effects of the tested methods.
In general, this study was able to demonstrate the short-term
effectiveness of single-tuft brushes, though it must be stressed that
they should only be used as an adjuvant strategy to conventional
brushing to tackle crevicular areas of buccal and lingual surfaces
in the same way as dental flossing is combined to conventional
brushing to tackle interdental areas.
In conclusion, the single-tuft brush tested in this study was
effective at controlling short-term dental biofilm new formation
at the dentogingival area.
The authors wish to acknowledge Bitufo - Hypermarcas for
providing the materials tested in this study.
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