Dental Plaque Removal Ability of Different Power Toothbrushes by Using a Three-Dimensional Study Model
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Original Article Int J Clin Prev Dent 2020;16(3):105-110ㆍhttps://doi.org/10.15236/ijcpd.2020.16.3.105
ISSN (Print) 1738-8546ㆍISSN (Online) 2287-6197
Dental Plaque Removal Ability of Different Power
Toothbrushes by Using a Three-Dimensional Study
Model
1,2 3 3 3
Mohammad Ali Saghiri , Armen Asatourian , Ali Mohammad Saghiri , Fatereh Samadi ,
1
Steven M Morgano
1
Department of Restorative Dentistry, Rutgers School of Dental Medicine, Newark, NJ, 2Department of Endodontics, University
3
of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA, Sector of Angiogenesis Regenerative Medicine, Dr.
Hajar Afsar Lajevardi Dental Material and Devices Group (ADMD), Hackensack, NJ, USA
Objective: This study was performed to evaluate the ability of four different electric power toothbrushes to remove dental
plaque on a three-dimensional (3-D) study model.
Methods: A 3-D, 360-degree model of 32 human teeth was made of polyester (ELEGOO Inc.). Then, eight photos were made
(four teeth at a time) from each quadrant and used as the negative control group (0% plaque). Then plaque-like color spray
chalk were added and cured on the teeth model; photos were made and used as the positive control group (100% plaque).
The 3-D model of the teeth was placed on a rotatable axis and immersed in a basin mimicking the composition of artificial
saliva and toothpaste. An apparatus with a mechanical arm was made to hold the toothbrushes during the plaque removal
process and control the force of brushing. Twenty-four toothbrushes were prepared and divided into four experimental
groups of 6 (n=6) including 1) Philips, 2) Oral-B, 3) Quip, and 4) Waterpik. Toothbrushing was performed for 2 minutes.
After brushing, photos were taken, and the percentage of plaque removal was measured by using the ImageJ software. Data
were analyzed by Kolmogorov–Smirnov, ANOVA, and post hoc Tukey tests.
Results: The highest plaque removal values were observed in the Philips group, and the lowest were seen in the Quip group.
Significant differences were only recorded between the values of Philips and the other groups (p＜0.05).
Conclusion: Within 2 minutes of brushing time, none of the power toothbrushes could completely remove artificial dental
plaque.
Keywords: dental plaque, oral hygiene, toothbrushing
Introduction
Corresponding author Mohammad Ali Saghiri
E-mail: saghiri@gmail.com Dental plaque is a sticky and colorless film [1] that begins
https://orcid.org/0000-0002-5064-7828 with the accumulation of an acellular organic material known
Received July 16, 2020, Revised September 13, 2020, as “pellicle’ on the exposed tooth surfaces [2,3]. This organic
Accepted September 21, 2020 coating is derived from saliva and is insoluble in oral fluids.
The thickness of this organic layer varies between 0.1 to 1.0
Copyright ⓒ 2020. Korean Academy of Preventive Dentistry. All rights reserved.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
105International Journal of Clinical Preventive Dentistry
µm. Normally, the pellicle is formed immediately after clean- and medical treatments are oral health related. Poor oral health
ed tooth surfaces are exposed to saliva. This layer is known to has an impact on learning, communication, self-esteem, and
be a protective layer for tooth surfaces that shields them from nutrition, which affects activities in school, work, and home
grinding and abrasive forces during mastication. Although [15]. The prevalence and severity of dental caries and perio-
this layer is a protective layer, it facilitates the development of dontal disease in the disabled population are significantly
dental plaque, which is a sticky, colorless film of bacteria that higher than the rest of the population [15]. The chronic nature
forms on teeth [4]. These bacteria can become firmly attached of dental diseases becomes more important when thinking of
to the pellicle by different forces such as electrostatic, hydro- patients with special needs who already may have a lifetime of
phobic ion, and van der Waals force. This irreversible adhe- compromised oral and physical health [15]. Poor oral hygiene
sion of microorganisms to the pellicle is followed by the coag- can have serious health implications. The inflammation pres-
gregation and accumulation of other microorganisms to the al- ent in periodontal disease has been linked to cardiovascular
ready adherent bacteria, which results in the diversity of the disease, while oral infection may cause bacterial endocarditis
plaque microflora. As these bacteria begin to grow, they pro- in susceptible patients with cardiac defects. Poor oral hygiene
duce a biofilm, which is the result of extracellular polymers can also place a person at risk for pulmonary infection and
composed of glucans and fructans, byproducts of sucrose lung disease [16].
metabolism. With the maturation of dental plaque, bacteria Among basic methods of oral health care, daily tooth-
become detached from the plaque biofilm to colonize on other brushing has been considered the most critical method for re-
tooth surfaces. These bacteria cause dental caries and are de- moving dental plaque [17]. Therefore, the aim of the present
scribed as “cariogenic bacteria.” These bacteria have several study was to evaluate the plaque removal ability of different
characteristics, including power toothbrushes by using an in-vitro 3-D study model. The
1. Rapid transport of fermentable carbohydrates and con- null hypothesis tested was that the power toothbrushes were
version to organic acid; not able to remove artificially made dental plaque from tooth
2. Production of extracellular and intracellular poly- surfaces.
saccharides;
3. Maintenance of carbohydrate metabolism under adverse Materials and Methods
conditions and stress [5-7].
Dental caries is one of the most prevalent infectious dis-
1. Teeth model preparation
eases in humans. Demineralization and remineralization
(repair or healing) of enamel are continuous processes. They A 3-D, 360-degree model of all 32 human teeth was made of
are intimately related, and occur episodically based on the polyester (ELEGOO Inc., Shenzhen, China [18]) (Figure 1A).
presence of cariogenic bacteria in dental plaque and the avail- The 3-D model of the teeth rotated on an axis and was dipped
ability of refined carbohydrates for fermentation to organic periodically in a basin to mimic the composition of human
acids [8]. In addition to dental caries, a complex three-dimen- salivary amylase and toothpaste. A mechanical arm was then
sional (3-D) arrangement of bacteria in a self-sustaining com- used to brush the teeth, adding force and motion to remove the
munity has been associated with the initiation and progression artificial dental plaque.
of gingivitis and the onset of periodontitis [9-12]. Plaque-in-
2. Photo preparation
duced gingivitis begins at the gingival margin, and the virulent
pathogens can progress throughout the gingival unit [13]. The teeth that are seen in the model mimic the composition
Irreversible damage may occur when microbes migrate more of hydroxyapatite and other molecules that were incorporated
in-depth into the epithelium [14]. Many patients, because of in the natural tooth structure. The teeth in this model were la-
difficulty in maintaining thorough oral hygiene, accumulate beled 1-32; 1-16 represented the teeth that make up the maxil-
significant amounts of bacterial plaque that contains virulent lary arch, and 17-32 represented the teeth in the mandibular
pathogens [10]. Effective oral hygiene is essential for all in- arch. After they were numbered, the teeth were divided into 4
dividuals, and it is especially crucial for those who are com- quadrants, and each quadrant was further divided into 2 parts,
promised as a result of poor manual dexterity, an immune sys- producing 8 parts that contain four teeth per part by using a cir-
tem deficiency, or chemotherapeutic or radiation therapy [11]. cular guide (Figure 1B, 1C). Next, eight separate photos were
One of the important issues regarding public health is oral made, only displaying four of the teeth at a time in each photo;
health care and dental hygiene. The link between oral health therefore, there were two photos for each quadrant.
and systemic health has shown that many systemic diseases
106 Vol. 16, No. 3, September 2020Mohammad Ali Saghiri, et al：Dental Plaque Removal of Toothbrushes
Figure 1. (A) The three-dimensional
(3-D) model from above. (B) The
circular guide divided the model
into 8 equal parts. (C) The figure of
the overlapping of circular guide on
the 3-D model. (D) The robotic
device used for holding the tooth-
brushes during brushing action.
There were 6 toothbrushes from each type per group. Tooth-
3. Photo evaluation
brushing was performed for 2 minutes. The chalk was brushed
Once the photos were made, a processing software, Image and left to dry for several seconds. Again, photos of the se-
J [19], was used to display all eight photos made. By using this lected teeth were made of the spray chalk, and the photos were
software, a 3-D model in a 2-D plane could be seen, with the uploaded to the computer. By using ImageJ software and
teeth in sequential order. Images were placed one by one. The changing the photo to type 8 bit for better clarity and improved
images were inverted, changed to 8-bit for better resolution, resolution, precise calculations were made to find the mean,
and then a box was placed over the teeth of interest to show the standard deviation, and area of the white shaded region
surface area. A measurement was shown in the area in a box. (Figure 2).
This procedure was performed for each of the photos.
5. Statistical analysis
4. Model teeth chalk distribution and brushing
Data were analyzed by Kolmogorov–Smirnov test proto-
To demonstrate the plaque on the teeth, white color spray col, one-way ANOVA, and post hoc Tukey tests at the level of
chalk (Testors 306006 Spray Chalk; Testors, Vernon Hills, IL, significance of pInternational Journal of Clinical Preventive Dentistry
Figure 2. The sequence of image
analysis by ImageJ software. (A)
Micrograph of the disc of labial
surface. (B) Inversion of image for
calculation and better detection of
artificial plaque. (C) Enhancement
of contrast and adjustment of the
threshold for better calculation. (D)
Converting the image to an 8-bit
type. (E) Calculation of the percen-
tage amount of remaining artificial
plaque on the surface.
Discussion
The present study intended to evaluate the ability of differ-
ent power toothbrushes to remove artificial dental plaque by
using a 3-D in-vitro model. In studies that are designed for
evaluation of the efficacy of dental plaque removal, several
variables are required to be taken into considerations. These
variables include the frequency of toothbrushing, duration of
toothbrushing, dental arch anatomy, as well as the manual
dexterity and motivation of the user [20,21]. It has been shown
that if these variables are not well controlled, false and in-
accurate results can occur with plaque removal studies [20].
Therefore, in the present study, a 3-D study model was used to
Figure 3. The box plot of means and standard deviations of the
percentage of plaque removal values of experimental groups control the variables, such as dental arch anatomy, manual
(regarding the box plot of Philips group, the number 2 is repre- dexterity, user motivation, and toothbrushing pressure.
senting an outlier data in this group). Regarding the toothbrushing time, thirty seconds of brushing
time is considered acceptable for each quadrant, which results
by the one-sample Kolmogorov–Smirnov test resulted in a in 2 minutes of total brushing time [20].
normal distribution of data. The one-way ANOVA test re- Power toothbrushes have been developed to improve oral
corded significant differences among experimental groups hygiene [22]. Power toothbrushes use different mechanisms
(pMohammad Ali Saghiri, et al：Dental Plaque Removal of Toothbrushes
the Quip electric toothbrush uses vibrations for the removal of 2) Principal findings
dental plaque. It appears that these mechanisms have a supple- This study inferred that though power toothbrushes are ef-
mentary effect on toothbrushing action that results in im- fective; toothbrushing for just 2 minutes is not sufficient for
proved plaque removal ability of the power toothbrushes. complete removal of dental plaque.
Similarly, the present study outcomes indicated that the tested
power toothbrushes were capable of removing artificial pla- 3) Practical implications
que very well. These results were consistent with previous The increasing of toothbrushing time, frequency, and/or
studies that reported a reduction in dental plaque and gingivi- types of brushing methods can be regarded as useful strategies
tis with power toothbrushes that produced rotating-oscillating in improvement of power toothbrushes’ efficacy in removal of
or sonic action when compared with manual toothbrushes dental plaque during daily oral hygiene.
[24-27].
Among the experimental groups, the Sonicare Philips Conclusion
toothbrushes recorded superior plaque removal activity com-
pared with the other groups. There was no significant differ- Under the limitations of this study, the following con-
ence among the other three experimental groups. In a previous clusions were drawn:
study by Putt et al. [28], Philips Sonicare FlexCare toothbrush • All tested power toothbrushes could remove accumulated
produced better plaque removal efficacy when compared with artificial plaque very well. However, none of these brush-
Oral-B Triumph Professional Care 9000 power tooth brush. es were able to eradicate plaque entirely.
However, Taschner et al. [29] reported that after single-use • Among tested toothbrushes, Philips brushes recorded su-
clinical evaluation, the oscillating/pulsating power toothbrush perior ability at plaque removal compared with the other
was more effective at plaque removal than a high-frequency three toothbrushes.
power toothbrush. Similarly, in another study by Sharma et al.
[30] the action of the oscillating/rotating/pulsating Oral-B Acknowledgements
Professional Care 7000 and Oral-B 3D Excel toothbrushes
was more effective in plaque removal compared with the M.A.S. is a recipient of New Jersey Health Foundation
high-frequency toothbrush (Sonicare Advance). These differ- Innovation Award. This publication is dedicated to the memo-
ences in plaque removal efficacy of oscillating-rotating and ry of Dr. H. Afsar Lajevardi [31], a legendary pediatrician
Sonicare power toothbrushes might be explained by differ- (1953-2015). The views expressed in this paper are those of
ences in the mechanism of action of these toothbrushes, differ- the authors and do not necessarily reflect the views or policies
ent powers that were used in these studies, different method- of the affiliated organizations. The authors hereby announced
ologies, and plaque study models (clinical models versus that they have had active cooperation in this scientific study
in-vitro models). The limitations of the present study might be and preparation of the present manuscript. The authors con-
the direction of toothbrush movement, which includes only firm that they have no financial involvement with any com-
one direction of movement, while in conventional brushing mercial company or organization with direct financial interest
techniques, multiple directions and orientations might be regarding the materials used in this study.
used. As an eye to the future, it would be beneficial to conduct
more in-vitro and clinical trials to justify the outcomes of the Conflict of Interest
present study. In addition, more complex in-vitro models, in-
cluding more directions of action for toothbrushes during No potential conflict of interest relevant to this article was
toothbrushing trials, can be recommended for future reported. The views expressed in this paper are those of the au-
investigations. thors and do not necessarily reflect the views or policies of the
affiliated organizations. The authors hereby announced that
1. Clinical relevance they have had active cooperation in this scientific study and
1) Scientific rationale for the study preparation of the present manuscript. The authors confirm
Toothbrushing is the most important part of daily oral that they have no financial involvement with any commercial
hygiene. Although, power toothbrushes showed promising re- company or organization with direct financial interest regard-
sults in removal dental plaques, but the evaluation of the actual ing the materials used in this study.MAS worked as Clinical
efficacy of these toothbrushes can help us in order to improve Biological Scientist for Philips Oral Health care (WA, USA)
the efficacy and ability of these brushes. during 2018-19.
www.ijcpd.org 109International Journal of Clinical Preventive Dentistry
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18. Shenzhen Elegoo Technology Co., Ltd. ELEGOO [Internet].
Armen Asatourian, https://orcid.org/0000-0002-5948-1465
Shenzhen: Shenzhen Elegoo Technology Co., Ltd [cited 2020
Ali Mohammad Saghiri, https://orcid.org/0000-0003-0797-314X
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Fatereh Samadi, https://orcid.org/0000-0002-2445-3288 19. Wayne Rasband. ImageJ [Internet]. Bethesda (MA): National
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