Sandhya P Naik et al 10.

5005/jp-journals-10024-2229
ORIGINAL RESEARCH

Effectiveness of Different Bristle Designs of Toothbrushes

and Periodontal Status among Fixed Orthodontic Patients:
A Double-blind Crossover Design
1
Sandhya P Naik, 2Sameer Punathil, 3Praveena Shetty, 4Ipsita Jayanti, 5Md Jalaluddin, 6Anisha Avijeeta

ABSTRACT Results: In both phase 1 and 2 of this RCT, toothbrush with

Aim: The aim of the present study was to evaluate the effec-
tiveness of different bristle designs of toothbrushes and the
periodontal status among patients undergoing fixed orthodontic
treatment.
Materials and methods: This randomized controlled trial
(RCT) consisted of 45 adolescents (comprising 20 males and
25 females) undergoing fixed orthodontic treatment. The study
participants were randomly allocated to three groups, each
group being assigned a locally available toothbrush with a
particular design of toothbrush bristle. In the first test phase,
group I study participants were allocated to toothbrush with flat
bristles, group II study subjects were allocated to toothbrush with
zigzag bristles, and group III study participants were allocated to
toothbrush with crisscross bristles. The study participants were
recalled after 4 weeks to check the effectiveness of the allocated
toothbrushes. A washout period of 1 week was maintained to
ensure that there was no carryover effect of the different bristle
designs. In the second test phase, each patient used the oppo-
site toothbrush bristle design (group I: toothbrush with zigzag
bristles, group II: toothbrush with crisscross bristles, and group
III: toothbrush with flat bristles). Plaque scores were measured
using Turesky–Gilmore–Glickman modification of Quigley-Hein
plaque index (PI).
crisscross bristles exhibited maximum plaque reduction among
the three different bristle design toothbrushes following 30 days
(p = 0.312 ± 0.102 and 0.280 ± 0.110, respectively), which was
statistically significant.
Conclusion: It was concluded that all the three designs of
toothbrushes were effective in removing plaque in patients
with fixed orthodontic appliances. But among the three different
toothbrushes, toothbrush with crisscross bristles showed the
highest mean plaque reduction.
Clinical significance: Plaque accumulation around the orth-
odontic brackets and gingival margins is quite common among
the fixed orthodontic patients, who encounter difficulty in main-
taining good oral hygiene. Specially designed toothbrushes are
very essential for effective plaque removal among the patients
undergoing fixed orthodontic treatment.
Keywords: Bristles, Crossover design, Fixed orthodontic appli-
ances, Plaque.
How to cite this article: Naik SP, Punathil S, Shetty P, Jayanti I,
Jalaluddin M, Avijeeta A. Effectiveness of Different Bristle
Designs of Toothbrushes and Periodontal Status among
Fixed Orthodontic Patients: A Double-blind Crossover Design.
J Contemp Dent Pract 2018;19(2):150-155.

Source of support: Nil

1
Department of Public Health Dentistry, Government Dental Conflict of interest: None
College and Hospital, Mumbai, Maharashtra, India
2
Department of Pedodontics, Sree Anjaneya Institute of Dental INTRODUCTION
Sciences, Kozhikode, Kerala, India
3 The oral diseases most frequently occurring in human-
Department of Orthodontics and Dentofacial Orthopedics
Srinivas Institute of Dental Sciences, Mangaluru, Karnataka kind are dental caries and periodontal disease, and the
India causative factor of both is dental plaque. Personal and
4-6
Department of Periodontology, Kalinga Institute of Dental professional oral hygiene practices are the procedures
Sciences, Bhubaneswar, Odisha, India directed at the removal of dental plaque. Toothbrush is
Corresponding Author: Sandhya P Naik, Department of Public one of the most commonly used adjuncts for maintaining
Health Dentistry, Government Dental College and Hospital oral hygiene.1
Mumbai, Maharashtra, India, Phone: +919156388888, e-mail: During orthodontic treatment, oral hygiene measures
sandhya.chavan84@gmail.com
that are directed toward the removal of dental plaque

150

around the brackets and orthodontic appliances need to
become more effective. Plaque accumulation around the
fixed orthodontic appliances can be challenging for effec-
tive toothbrushing and can interfere with the mechanical
cleaning action of mastication. As the duration of orth-
odontic treatment is long, routine oral hygiene measures
for the orthodontic patient including professional tooth
cleaning and home care instructions must be given with
a lot of consideration.2
Effective home-plaque-control measures are very con-
ducive for maintaining a functional dentition throughout
life. These include toothbrushing by manual or electric
toothbrush combined with interdental cleaning. It is well
known that there is a positive correlation between the
degree of plaque accumulation and gingival disease. The
role of plaque as a causative factor in the development
of chronic inflammatory disease has been routinely con-
firmed in the scientific literature.3 Dental plaque causes
inflammatory process in the supporting structures of the
teeth, which, if progressed, results in tooth loss.4
The most effective method of achieving good oral
health in most of the population is the daily usage of
manual toothbrush.5 Since their first use by the Chinese
in the late 16th century, toothbrushes have gone through
changes in their basic structure. Various aspects, such as
size, shape, bristle arrangement, texture and stiffness,
head design, angulations between head, shaft and handle
along with other features, as well as many other modifica-
tions have been made.
In the present day, a very wide variety of toothbrushes
are available in the market. This has led to a dilemma
in the consumer’s mind with respect to efficacy of each
toothbrush. In addition, factors such as cost, availability,
advertising claims, family tradition, or personal habits
decide the type of toothbrush going to be used by a par-
ticular person.6 Thus, the aim of the present study was
to evaluate the effectiveness of different bristle designs
of toothbrushes and the periodontal status among fixed
orthodontic patients.
MATERIALS AND METHODS
This RCT was conducted on 45 adolescent participants
(20 males and 25 females) undergoing fixed orthodontic
treatment, whose ages varied between 15 and 18 years.
Ethical approval along with informed consent was
obtained from the participants before the study. Detailed
information about the study design and procedure was
explained to the participants.
Patients with fully bonded fixed orthodontic appli-
ances and without any systemic diseases, patients who
had not taken any antibiotics or antiseptic mouthwashes
for 1 month before the study were included in the study.
The Journal of Contemporary Dental Practice, February 2018;19(2):150-155
JCDP
Effectiveness of Different Bristle Designs of Toothbrushes
The participants using chemical plaque control measures
and those taking drugs that could affect the state of gin-
gival tissues, including corticosteroids and nonsteroidal
antiinflammatory drugs, were excluded from the study.
Sample Size Determination
The formula used to calculate sample size was:
Z12−α / 2
n=
d2
n is the required sample size; Z1–α/2 is a constant; its
value for a two-sided test is 1.96 for 95%; d is absolute
precision 20% = 0.2.
As calculated from the above formula, 45 participants
were randomly allocated to three different types of locally
available toothbrushes with varied toothbrush bristle
designs groups (Flow Chart 1).
Study Groups
First test phase
• Group I: Toothbrush with flat bristles
• Group II: Toothbrush with zigzag bristles
• Group III: Toothbrush with crisscross bristles (Figs 1
and 2).
Second test phase
• Group I: Toothbrush with zigzag bristles
• Group II: Toothbrush with crisscross bristles
• Group III: Toothbrush with flat bristles.
Methodology
This was a double-blind crossover study, where a 1-week
washout period was given between the crossover phases
to evaluate the effectiveness of the three bristle designs
of toothbrushes among patients undergoing fixed orth-
odontic treatment.
The examiner was trained and calibrated before the
start of the study. Intraexaminer agreement for PI was
calculated by repeat measurements that were done on
10 patients not participating in the study, within an inter-
val of 1 hour. The Kappa coefficient for PI was found to
be 0.7. All the participants were given a similar type of
toothpaste. Toothbrushing technique instructions were
given to the participants for the purpose of standardiza-
tion. Furthermore, instructions to brush twice daily for
2 minutes (morning just after waking up and in the night
before going to bed) were given to the participants, along
with directions to use the same toothbrush and toothpaste
given to them.
Lottery method was used to randomly allocate all the
patients to the study groups according to the different
bristle designs of toothbrushes. Coding was done for
151
Sandhya P Naik et al
Flow Chart 1: Distribution of study participants
Fig. 1: Front view of all the three toothbrushes
each one of the toothbrushes. It was only at the end of the
study that the codes were decoded. In the first test phase,
the toothbrushes that were allocated were in the order:
• Group I: Toothbrush with flat bristles
• Group II: Toothbrush with zigzag bristles
• Group III: Toothbrush with crisscross bristles
On the first day of each phase, all the patients were
asked to refrain from any oral hygiene practices for
24 hours. Data regarding plaque scores were collected
by assessing plaque using Turesky–Gilmore–Glickman
Modification of Quigley-Hein PI.7 Two-tone disclosing
solution was used to evaluate plaque on the buccal and
lingual surfaces of all teeth except the third molars. The
participants were recalled following 4 weeks to assess the
effectiveness of the toothbrushes allocated to the three
study groups.
152
Fig. 2: Side view of all the three toothbrushes
The second test phase was carried out in a similar way,
after a 1-week washout period to negate the carryover
effects of the different bristle designs. Toothbrush bristle
designs were alternated in the order:
• Group I: Toothbrush with zigzag bristles
• Group II: Toothbrush with crisscross bristles
• Group III: Toothbrush with flat bristles
Statistical Analysis
Statistical analysis was done using the Statistical Package
for the Social Sciences software (version 20.0). Mean and
standard deviations (SDs) of the clinically examined
scores were calculated. Analysis of variance and post hoc
paired t-tests were applied to analyze differences between
the three different bristle designs. A p = 5% significance
level was maintained for all the analysis.
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Effectiveness of Different Bristle Designs of Toothbrushes

RESULTS
Overall, 45 patients (20 males and 25 females) were
included in the present study. Table 1 shows the com-
parison between the pre- and postbrushing scores for PI
in phase 1. Among all the three different bristle design
toothbrushes, group III (toothbrush with crisscross bris-
tles) shows the maximum plaque reduction after 30 days
(0.312 ± 0.102), following which group II (toothbrush with
zigzag bristles) 0.344 ± 0.012 and group I (toothbrush with
flat bristles) 0.516 ± 0.212 show plaque reduction respec-
tively. There was a statistically significant difference in
the reduction of plaque scores between groups II and III.
Table 2 shows the comparison between pre- and
postbrushing PI scores in phase 2. Following crossover,
among three different bristle design toothbrushes,
group II (toothbrush with crisscross bristles) is found
to have the maximum plaque reduction after 30 days
(0.280 ± 0.110), followed by group I (toothbrush with
zigzag bristles) 0.310 ± 0.142 and group III (toothbrush
with flat bristles) 0.390 ± 0.148 respectively. All the three
groups show a statistically significant difference in the
reduction of plaque scores.
Table 3 depicts Scheffe post hoc analysis, which indi-
cated that the average number of plaque removed is
significantly higher in group III than in groups II and I.
In phase 2, the post hoc analysis shows that the average
number of plaque removed is higher in group II than in
groups I and III, as observed from Table 4.
DISCUSSION
This was a double-blind crossover trial with a washout
period, conducted to evaluate the effectiveness of dif-
ferent toothbrush bristle designs in patients undergo-
ing fixed orthodontic treatment. It is well known that
the presence of orthodontic brackets and appliances
makes the patients vulnerable to plaque accumulation
around these sites. The advantages of using the cross-
over design are many; here the effects of the different
types of toothbrushes were measured in the same
person. The other advantages included lower number
of participants required for the study and confound-
ing factors within the participants (e.g., age, gender,
and hand skills). However, to minimize the carryover
effect, which is the main concern during the use of a
crossover design, we allowed for a 7 days washout
period, during which the patients went back to using
their normal toothbrushes.8,9
The manual toothbrush that we use in our daily life
was introduced in the 1920s; it has since then become
an affordable oral hygiene device for the population at
large. The most common oral hygiene habit in the last
decade is toothbrushing using toothbrush and tooth-
paste. Numerous innovative design improvements have
facilitated to increase the efficacy of a toothbrush. Most of
the variations/innovations that have been observed are
majorly pertaining to the design of the brush head and
configuration of the filaments.4

Table 1: Comparison of pre- and postbrushing PI scores in phase 1 Table 2: Comparison of pre- and postbrushing PI scores in phase 2
Groups Mean ± SD t-value Significance Groups Mean ± SD t-value Significance
Group I Group I
  Prebrushing 0.824 ± 0.192 10.24 0.08   Prebrushing 0.882 ± 0.186 9.74 0.001
  Postbrushing 0.516 ± 0.212   Postbrushing 0.310 ± 0.142
Group II Group II
  Prebrushing 0.868 ± 0.164 9.62 0.02   Prebrushing 0.844 ± 0.130 8.36 0.001
  Postbrushing 0.344 ± 0.012   Postbrushing 0.280 ± 0.110
Group III Group III
  Prebrushing 0.782 ± 0.126 8.14 0.001   Prebrushing 0.712 ± 0.012 8.96 0.02
  Postbrushing 0.312 ± 0.102   Postbrushing 0.390 ± 0.148

Table 3: Multiple comparison of all the toothbrushes using post Table 4: Multiple comparison of all the toothbrushes using
hoc Tukey’s test in phase 1 post hoc Tukey’s test in phase 2
Groups Mean difference Standard error Significance Groups Mean difference Standard error Significance
Group I Group I
  Group II –0.216 0.062 0.82   Group II 0.008 0.004 0.14
  Group III –0.162 0.081 0.01   Group III 0.250 0.062 0.02
Group II Group II
  Group I 0.216 0.066 0.22   Group I –0.008 0.004 0.26
  Group III 0.054 0.082 0.10   Group III 0.242 0.050 0.01
Group III Group III
  Group I 0.162 0.084 0.01   Group I –0.250 0.094 0.02
  Group II –0.054 0.090 0.12   Group II –0.242 0.050 0.01

The Journal of Contemporary Dental Practice, February 2018;19(2):150-155 153

Sandhya P Naik et al
The present study was conducted for 30 days (4 weeks)
for each of the test phases. According to a study by
Cohen,10 trial periods of 3 weeks are advisable if a tooth-
brush needs to be tested accurately. We found that the
findings of this study were in accordance with Cohen10
depicting the trend toward progressive reduction in
plaque scores among all the types of study brushes used
during the 4 weeks of the trial. In a trial conducted by
Scopp et al,11 the experimental toothbrush was found
to produce lowest plaque scores in the 1st week, which
was in contrast with our findings. One possible explana-
tion could be that patients tend to revert to the same old
technique they are most comfortable with.
At baseline, the plaque scores were almost similar
in all the groups during each test phase. The results
showed statistically significant differences between the
three toothbrushes. This is in contrast to the findings of
the study done by Bergenholtz et al,12 who compared a
flat-trim toothbrush with V-shaped bristles and found
no significant differences between the toothbrushes. In
another study, Staudt et al13 compared the efficacy of
three different toothbrushes, which were convex bristle,
multilevel bristle, and flat-trim bristle. This study used
a computer-based planimetric PI, which is considered
to be superior in terms of sensitivity, objectivity, and
reliability. Our study was found to be in accordance
with the study conducted by Keiser and Groeneveld,14
where all the toothbrushes showed reduction in plaque
scores.
In the present study, all the three toothbrushes showed
significant reduction of plaque scores, to a greater or
lesser degree (p < 0.05). This is in accordance with most
of the studies, such as Claydon et al,15 Ashri et al,16 and
Versteg et al.17 However, the difference between the pre-
and postbrushing plaque scores among toothbrush with
crisscross bristles was more as compared with the other
two toothbrushes.
In a single-blind crossover study conducted by Stroski
et al,18 the performance of various toothbrush models for
controlling plaque was compared. The three toothbrushes
were capable of efficiently removing plaque. The arrange-
ment of the bristles had little effect over plaque removal.
Interestingly enough, the findings of our study demon-
strated that all the bristle designs were almost effective
in removing dental plaque and that a slight superiority
was shown by crisscross design in reducing plaque scores.
Compared with most dental procedures, a good
toothbrush is relatively very economical. Appropriately
choosing the best toothbrush requires choosing the right
bristle designs. In general, individual preference governs
the selection of bristle design. The result of our study is
in contrast to that of Rustogi et al,19 where Navy index
was used to quantify the plaque. The study conducted by
154
Sharma et al20 compared five toothbrushes having flat-
trimmed bristles, multilevel straight bristles with three
advanced crisscross bristles, concluding that crisscross
bristles were superior, which was similar to our results.
Another study conducted by Kakar et al21 revealed that
zigzag bristles showed increase in percentage reduction
of PI scores, which are in contradiction to the present
study results.
However, the efficacy and relative effectiveness of
various types and designs of toothbrushes should be
confirmed through long-term studies with larger sample
size, with the further assessment of the plaque removal
efficacy along with a long-term follow-up throughout the
orthodontic treatment.
Fixed orthodontic treatment makes the patients vul-
nerable to plaque accumulation around the orthodontic
brackets and gingival margins, complicating mainte-
nance of good oral hygiene. Hence, it is suggested to use
specially designed toothbrushes for easy and effective
toothbrushing.
CONCLUSION
All the three designs of toothbrush bristles were effec-
tive in removing plaque among the patients undergoing
fixed orthodontic treatment. Out of the three different
toothbrushes, toothbrush with crisscross bristles showed
the highest mean plaque reduction.
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