J Ciin Periodonto! 1998: 25: 829-831Primed in Denmark . AU rights reserved

Copyright C' Munksgaard 1998

ISSN

Comparison of 2 toothbrushingmethods for efficacy insupragingival plaque removalThe Toothpick method and theBass method

M, Morita, K, Nishi and T, WatanabeDepartment of Preventive Dentistry, OkayamaUniversily Dental School, Okayama, Japan

Morita M. Nishi K, Watanahe T: Comparison of 2 toothbrushing methods forefficacy in supragingival plaque removal. The Toothpick method and the Bassmethod J Ciin Periodontol 1998: 25: 829-831. © Munksgaard. 1998.

Abstract. Plaque removing efficacy was compared between a new toothbrushingmethod named the Toothpick method and the Bass method, 20 male universitydental students participated in the study, which consisted of 2 experiments. Priorto each experiment, all subjects were asked to abstain from all oral hygieneprocedures for 48 h. In Exp, I, plaque-removing efficacy was assessed after eachparticipant's mouth had been professionally brushed by a dentist. In this experi-ment, 2 quadrants were brushed professionally using the Toothpick method, andthe remaining 2 quadrants were brushed using the Bass method. The brushingtime amounted to a total of 2 min per mouth. In Exp, 11. the subjects brushedtheir own teeth after receiving toothbrushing instruction, A blind examiner as-sessed dental plaque using a modification of the Quigiey and Hein index at 6sites around each tooth, Toothbrushing using the Toothpick method was foundto remove significantly more plaque from proximal tooth surfaces than brushingusing the Bass method.

Key words: oral hygiene; Toothpick method;Bass method; manuai toothbrushing

Accepted for pubiication 17 February 1998

The Bass method of toothbrushing(Bass 1954) is one of the most com-monly recommended techniques in den-tal practice (Rylander et al. 1985). In1984, we have established a new tooth-brushing method named the Toothpickmethod (Watanabe et al, 1984), TheToothpick method was developed to re-move interdental plaque using only anordinary toothbrush. Although clinicalreports have demonstrated the effective-ness of the Toothpick method (Montaet al, 1995, Kim et al. 1997), no datasupporting the Toothpick method overother toothbrushing methods have beenpublished. Thus, we compared theToothpick and Bass methods forplaque-removing efficacy. Becauseplaque-removing efficacy increases with

brushing time (Hawkins et al. 1986. Vander Weijden et al, 1993). toothbrushingduration was standardized in the pres-ent study.

Material and Methods

20 male university dental students wereselected. Their ages ranged from 24 to26 years. They were screened to excludethose having: (a) orthodontic banding;(b) crowding: (c) fewer than 6 naturalteeth in each quadrant; (d) periodontalpockets 3=4 mm. No students were tak-ing antibiotics during the study. Priorto each experiment, all the subjects re-ceived professional tooth cleaning andscaling.

Experiment I: Professional toothbrushing

The subjects were asked to abstain fromoral hygiene procedures for 48 h. Subse-quently, 1 examiner (KN) evaluated theamount of dental plaque using a modi-fication of the Quigiey & Hein Index(Turesky et al. 1970), Plaque wasstained with erythrocine. 6 surfaces ofeach tooth were scored; mesial, middleand distal examined from both the buc-cal and lingua! aspect.

Each participant's mouth wasbrushed in a split-mouth order by a 2ndexaminer (MM) using the 2 brushingmethods in the absence of the 1st exam-iner (KN), In random order, either the1st and 3rd quadrants or the 2nd and4th quadrants were brushed using the

830 Morita et al.

Toothpick method. The 2 remainingquadrants were brushed professionallyusing the Bass method. The toothbrushhad 2 rows of nylon bristles, 6 tufts perrow, 50 filaments (0=0.2 mm) per tuft.The time available for brushing wasstandardized to 30 s per quadrant andwas monitored using a stopwatch. Notoothpaste was used in the experiment.The 1st examiner (KN). who had noprior knowledge of the assignation ofthe quadrants, then re-evaluated theamount of dental plaque remaining.

Experiment ii: Toothbrushing by theparticipants after toothbrushing instruction

The same 20 subjects were instructed tobrush their teeth using the Bass and theToothpick methods, and then asked toabstain from oral hygiene proceduresfor 48 h prior to this experiment. Afterplaque accumulation, supervised tooth-brushing was performed by the partici-

pants according to the split-mouth de-sign, and using the same toothbrushingmethod as in Experiment I. The timeavailable for toothbrushing was 30 s perquadrant.

The Toothpici( method

The tips of the bristles are placed on thegingival margin toward the crown at a30 degree angle to the long axis of theteeth (Fig, la), as in the Charters'method (Rylander et al, 1985), Thebristles are pressed into interdentalspaces and pulled out, just like a"toothpick", from the buccal (Fig, Ib)and the lingual aspects (Fig, lc). Thispiston motion is repeated 8-9 times inone region (Watanabe et al, 1984),Using this technique, removal of inter-proximal plaque is possible without theneed for dental floss or an interdentalbrush. The number of toothbrushbristles inserted depends on the inter-proxima! space. .A small number ofbristles can be inserted in a small inter-dental space, whereas 1 or 2 tufts areapplicable in wide interdental spaces.

Data analysis

The mean plaque index was calculatedseparately for the buccal/lingual sur-faces and for the proximal surfaces foreach set of quadrants for all individ-uals. The differences between the end-of-trial scores of the 2 toothbrushing

methods were assessed using the analy-sis of covariance (ANCOVA), The base-line score (48-h plaque accumulation)was used as a covariate. Comparison ofthe % reduction between the 2 tooth-brushing methods was performed usinga Wilcoxon test for matched pairs. Stat-istical significance was established atthe ;j<0,05 level.

Results and discussion

The Toothpick method removed signifi-cantly more plaque than the Bassmethod after 30 s of toothbrushing perquadrant, as assessed at interproximalsurfaces, in both the professional tooth-brushing (Table 1) and parlicipamtoothbrushing experiments (Table 2),Plaque removal from buccal/lingual sitesdid not differ in either experiment be-tween the 2 brushing methods. The mean"A reductions in the plaque scores weresignificantly higher at the sites brushedusing the Toothpick method than thosebrushed using the Bass method, as as-sessed at interproximal surfaces (Exp, 1;Toothpick method. 1.39; Bass method,0.90. Exp, II; Toothpick method, 1,38;Bass method, 0,95),

Studies comparing interproximalplaque-removing efficacy of differentmanual toothbrushing methods haveconcluded that the interproximal areasare inaccessible to the toothbrush(Hansen & Gjermo 1971, Bergenholtzet al. 1984). Furthermore, although the

Table 1. Mean plaque index and % reduction in the profenssional toothbrushing experiment

approximal

buccal/lingual

Brushingmethods

ToothpickBass

ToothpickBass

Mean

baseline

2.36±0,552.24±0,55

2,30 = 0,612,24=0,61

plaque scores

end scores

0.97±0,28***1.34±O,35

0,95 = 0,320,95 = 0,41

MeanVn reduction

57,5±12,5+39.8±9,4

58,.1± 10,555,7=14,0

Mean±SD,Significantly lower than the Bass method (**' p<0,001).Significantly higher than the Bass method C /i<0,01).

Table 2. Mean plaque index and % reduction in the participant toothbrushing experiment

approximal

buccal/lingual

Brushingmethods

ToothpickBass

ToothpickBass

Mean

baseline

2,37±0.512.28±0.53

2,31 ±0.562.17±O,5O

plaque scores

end scores

0,99 = 0,41**1,33 = 0,47

0,92±0,4!0,84±0,52

Mean% reduction

57.8 ±13.9-41,6±14,1

59.9±14.561,9±19.6

Fig. 1. The Toothpick method.

Mean±SD,Significantly lower than the Bass method (** jti<0.01).Significantly higher than the Bass method C y5<0,01).

Comparison of toothbrushing methods 831

Bass method is more effective on lin-gual axial surfaces than the Roll, theCircular Scrub and Horizontal Scrubmethods, none of these brushingmethods was superior to the others ininterproximal plaque-removing efficacy(Bergenholtz et al. 1984),

In the present study, the duration oftoothbrushing was standardized to 30 sper quadrant (2 min for a wholemouth), because comparison of plaque-removing efficacy after 2-min tooth-brushing is clinically practical. The av-erage brushing time of patients at adental clinic is actually 56,7 s for thewhole mouth and ranges from 15 to155s(Emlinget al, 1981),

The present study is based on a pre-viously reported design (Van der Weijd-en et al, 1995). The purpose of the pro-fessional brushing part of the study wasto assess the efficacy of the 2 tooth-brushing methods without individualvariation.

The mean interproximal plaque scoreat the sites brushed using the Bassmethod was lower (1,33 in Exp, II) thanthe result (2,20) obtained by Tritten etal, (1996), who used the same plaqueassessment technique and brushingtime. This difference may be due to thedisparity between the ages of the 2study groups, as Tritten et al, (1996) re-cruited older subjects (mean age ; 32years). Since the Quigiey & Hem indexis based on vision, some problems doarise when assessing low plaque ac-cumulation. Specifically, wider inter-proximal sites are clearly visible,whereas interproximal spaces with pa-pilla are inaccessible to the eyes.

The toothpick method is more diffi-cult to master than the Bass method,and it should be borne in mind that ourresults showing increased efficacy of theToothpick method in plaque removalwere obtained using Senior Dental Stu-dents with high levels of manual dex-terity. Further research will focus on theextent to which this method can be suc-cessfully mastered by ordinary mem-bers of the public.

Zusammenfassung

Vergleich zweier Zahnputzmethoden hinsicht-lich ihrer Effektivitdt bei der supragingivalenPiaqueentfernungZwischen 2 neuen Zahnputzmethoden, derZahnholzmethode und der Bass-Technik.wurde die Effektivitat der Plaqueentfernungverglichen. 20 mSnnliche Zahnmedizinstu-denten nahmen an einer Untersuchung teil,die aus 2 Experimenten bestand, Vor jedem

Experiment wurden alle Teilnehmer gebeten,ftir 48 Stunden alle MundhygienemaBnah-men zu unterlassen. In Experiment 1 wurdedie Effektivitat der Plaqueentfernung gemes-sen nachdem die Zahne von einem Zahnarztprofessioneil gereinigt worden waren. In die-sem Experiment wurden 2 Quadranten pro-fessioneil mit der Zahnholzmethode gereinigtund die restlichen 2 wurden nach der Bass-Technik geputzt. Die Putzzeit betrug insge-samt 2 Minuten pro Mund, In ExperimentIi putzten die Personen ihre eigenen Zahne,nachdem sie eine Zahnputzinstruktion erhal-ten hatten, Unter Verwendung des modifi-zierten Quigley-Hein-Index wurde von einemunabhangigen Uniersucher die Zahnplaquean 6 Stellen pro Zahn bestimmt. Es wurdevorgefunden. daB die Zahnholzmethode si-gnifikant mehr Plaque aus den Interdental-raumen entfernte, als das Putzen nach derBass-Technik,

Resume

Comparaison de Vefficacite de 2 methodes debrossage des dents dans I'elimination de la pla-que sus-gingivale. La methode "cure-dent"(methode Toothpick "j et la methode de BassUefficacite de I'elimination de la plaque parle brossage des dents en employant la me-thode appelee "Toothpick" (methode "cure-dent") a ete comparee a celle obtenue en em-ployant la methode de Bass, Cette etude, alaquelle participaient 20 sujets du sexe mas-culin. etudiants d'une universite dentaire.consistait en 2 experiences, Avant chacunedes experiences, tous les sujets ont ete priesde s'abstenir de tout soin d'hygiene bucco-dentaire pendant 48 h, Dans l'Exp. I. i'effi-cacite de I'elimination de la plaque a ete me-suree apres que tous les participants aientsubi un brossage professionnel fait par undentiste, Dans cette experience, le dentistebrossait deux des quadrants en employant lamethode "cure-dent", et les deux autres qua-drants avec ia methode de Bass. La duree dubrossage se montait a un total de 2 min parbouche. Dans l'Exp, II, les sujets se bros-saient les dents eux-memes apres avoir re?uun enseignement du brossage des dents, Unexaminateur ignorant la methode employeedans les differents quadrants enregistrait laplaque dentaire en utilisant une modificationde la methode de Quigiey et Hein au niveaude 6 sites autour de chacune des dents. On aconstate que le brossage par la methode"cure-dent" enlevait significativement plus deplaque sur les faces proximales des dents quelorsqu'on utilisait la methode de Bass,

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Address;

Tatsuo WatanabeDepartment of Preventive DentistryOkayama University Dental SchoolShikata-choOkayama 700-8525Japan