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An investigation into toothbrush wear related to months of use among university students.

ABSTRACT

Background: Toothbrushes should be replaced every 3 to 4 months as older brushes lose their plaque removal ability. Older brushes may not be able to remove plaque from pits and fissures seen on the occlusal surfaces of the teeth or from the proximal areas between the teeth. The purpose of this study is to evaluate the wear seen on used toothbrushes (UTB) and the relation of wear with regards to the period of toothbrush use. Material and methods: UTB were collected from university students studying courses in arts and sciences faculties, excluding health sciences faculties, during an oral health awareness campaign conducted by the Faculty of Dentistry. A validated questionnaire was used to collect descriptive data regarding toothbrushing habits. Two calibrated examiners scored the UTB according to the Rawls et al. index. Authors also examined different types of toothbrushes and the cleanliness of the toothbrush handles. Results: The findings of the study show that 58.0% of the UTB were in good condition for optimal plaque removal (scores 0 and 1), whereas the remaining 42% were not in suitable condition for optimal plaque removal (scores 2 and 3). The UTB measured with Rawls et al.'s index were used for 2.7,4.5, 5.9, and 7.0 months (mean number of months), respectively. Conclusion: Many factors, in addition to period of use, come into play with regards to the splaying of toothbrush bristles. Dental professionals should educate their clients about and reinforce the need to replace toothbrushes after 3 to 4 months of use or after significant wear of the bristles, whichever comes first.

RESUME

Contexte : Il est conseille de remplacer les brosses a dents tous les 3 a 4 mois, car les vieilles brosses perdent leur capacite d'eliminer la plaque. Les vieilles brosses a dents sont moins susceptibles d'eliminer la plaque dentaire situee dans les regions proximales ou dans les puits et fissures des surfaces oeclusales. L'objectif de la presente etude consiste a evaluer l'usure decelee sur les vieilles brosses a dents (VBD) et a examiner le lien entre l'usure des poils et la periode d'utilisation de la brosse a dents. Materiel et methodes : Lors d'une campagne de sensibilisation a la sante buccale menee par la faculte de dentisterie, les VBD ont ete recueillies aupres des etudiants universitaires suivant des cours a la faculte des arts et des sciences, a l'exception de la faculte des sciences de la sante. Un questionnaire valide a servi a la collecte de donnees descriptives en matiere d'habitudes de brossage de dents. Deux examinateurs specialement formes a l'etalonnage ont evalue les VBD selon l'indice de Rawls et coll. Les auteurs ont aussi examine les differents types de brosses a dents ainsi que la proprete de leurs manches. Resultats : Les resultats de l'etude montrent que 58 % des VBD etaient en bon etat pour eliminer la plaque de facon optimale (scores de 0 et 1), alors que les autres 42 % n'etaient pas dans un etat convenable pour eliminer la plaque de facon optimale (scores de 2 et 3). Les VBD qui ont ete evaluees selon l'indice de Rawls et coll. avaient ete utilisees respectivement pendant 2,7, 4,5, 5,9 et 7 mois (nombre moyen de mois). Conclusion : L'evasement des poils d'une brosse a dents peut etre cause par de nombreux facteurs, autres que la periode d'utilisation. Il est important que les professionnels du domaine dentaire soulignent a leurs clients l'importance de remplacer leurs brosses a dents apres 3 a 4 mois d'utilisation ou lorsque l'usure des poils est significative, selon la premiere eventualite.

Key words: adults, charcoal-coated brush, renewal/replacement, toothbrush wear

INTRODUCTION

Toothbrushes serve as the main aids for mechanical plaque removal from the labial/facial, lingual/palatal, and occlusal surfaces of the teeth. (1) Brushing technique and the condition of the toothbrush serve as the major determinants for the efficacy of plaque removal by the toothbrush. (1) Conforti et al. conducted a study wherein worn and new, manual and powered toothbrushes were compared for their plaque removing efficacy. (2) The results showed that worn toothbrushes had significantly less ability to remove plaque, especially from the proximal areas. (2) The ability of worn toothbrushes to clean pits and fissures on the occlusal surfaces of the teeth is reduced. While the American Dental Association (ADA) recommends that toothbrushes be replaced every 3 to 4 months, (3,4) this time period may not be practically applicable to every individual, because the amount of force used, pattern, duration of brushing, and socio-economic factors vary from individual to individual. The ADA advises individuals to check for any sort of wear on the bristles and replace them more frequently if needed. (3) As bristles of the brush fray and wear with use, the cleaning effectiveness of the brush decreases. The purpose of this study was to analyse the correlation between toothbrush bristle wear and period of time of toothbrush use among university students.

MATERIAL AND METHODS

This study was approved by the Institutional Ethics Committee of SEGi University (Selangor, Malaysia). UTB were collected from participants during an oral health awareness campaign "Smile campaign 2014" organized by the Faculty of Dentistry. Participants were university students pursuing courses in mass communication, education, business administration, information technology, and engineering. Students pursuing courses in medicine, dentistry, and allied health sciences were excluded from the study. The UTB were collected as part of the oral health awareness campaign wherein new tooth brushes were distributed to the participants in exchange for their old UTB. Descriptive data regarding the toothbrushing habits were collected through a validated questionnaire which included questions regarding the frequency and duration of brushing sessions per day, and period of use of current toothbrush in months. Those UTB from participants who indicated that they were brushing once daily and those who were brushing twice daily irregularly were excluded from the study. A total of 121 UTB, used twice daily for a period of around 2 minutes by the participants, were included in the study. Two examiners were calibrated for scoring UTB wear according to the Rawls et al. index. (5) Based on this index, a score of 0 is given when it is impossible to determine if the toothbrush was used or not; score 1, when the bristles of the toothbrush seem to be separated within some tufts; score 2, when most tufts are separated, many cover other tufts, and present a large number of curved and inclined bristles; and score 3, when most of tufts are covered by other bristles and bristles are folded and tipped. Toothbrushes with scores of 0 and 1 are in suitable condition for optimal plaque removal, whereas those with scores of 2 and 3 are not suitable for optimal plaque removal. Table 1 outlines the scoring criteria and inferences about the toothbrush wear index given by Rawls et al. A representative image of the UTB according to the scores of the Rawls et al. index is shown in Figure 1.

The 2 examiners scored 121 UTB independently, and weighted kappa score values were calculated. A satisfactory kappa score of 0.86 was obtained for interexaminer agreement. The examiners re-examined the UTB that were differently scored and agreed upon a single score for each UTB. Later they re-examined the UTB and agreed upon one criterion to plot the data against the number of months of usage of toothbrush. Both examiners were blinded with regards to the information of period of use of each toothbrush when scoring the UTB wear according to the Rawls et al. index. Table 2 summarizes the weighted kappa scores for the 2 examiners SSR and KCG.

The examiners also assessed the cleanliness of the UTB handles, as it relates to the general attitude towards and importance accorded to oral hygiene aids. UTB handles and bristle bases were scored from 0 to 3 based on the presence of visible dirt (i.e., toothpaste deposits, food particles, other hard deposits) as shown in Table 3. A representative image of the UTB handles according to which scoring was carried out is shown in Figure 2.

RESULTS

In total, 121 UTB were included in the study to assess the wear seen on the bristles. Examiners found that 37.2% of UTB bristles were angulated, whereas 62.8% of UTB bristles were straight. Among the UTB, 14.9% were scored at 0 (it is impossible to state if the toothbrush was used or not), 43.0% were scored at 1 (the bristles seem to be separated within some tufts), 28.1% were scored at 2 (most tufts are separated, many cover other tufts and present a large number of curved and inclined bristles), 14.0% were scored at 3 (most tufts are covered by others and bristles are folded and tipped). The reliability of the 2 examiners (weighted kappa) who graded all of the UTB independently based on visual examination ranged from 0.79 to 0.92, which can be considered as a good interexaminer agreement. Duration of use of toothbrushes reported by participants is tabulated across the Rawls et al. index in Table 4. (Detailed tabulation of frequency and percentages against the Rawls et al. index is also provided). Of the 121 UTB that were examined, 42 (34.7%) were used for 3 months, and usage ranged from 1 to 9 months. The mean numbers of months for which the UTB were used, based on the Rawls et al. index score 0-3, are 2.7, 4.5, 5.9, and 7.0 months, respectively. Toothbrush bristle wear increased with the increase in mean number of months of toothbrush use. So, a direct relationship was observed between mean number of months of toothbrush use and scores of the Rawls et al. index.

The cleanliness of the UTB handle was also scored in our study. Out of 121 UTB, 65.0% were scored as having a clean handle and acceptable hygiene, 26.4% had visible dirt on less than one-third of the handle, 6.6% had visible dirt on more than one-third and less than two-thirds of the handles. A very small portion of the UTB had more than two-thirds of the handle covered with visible dirt. The presence of deposits at the base of the tufts was also assessed. Out of 121 UTB, 57.0% had toothpaste deposits, food particles, and other hard deposits at the base of the bristles.

DISCUSSION

The bristles of toothbrushes should be in good condition (Score 0 and 1 on the Rawls et al. index) for optimal removal of plaque from the pits and fissures as well as from interproximal surfaces of the teeth. The findings of this study show that 58.0% of the UTB were in good condition for optimal plaque removal (scores 0 and 1), whereas the remaining 42% of the UTB were not in suitable condition for optimal plaque removal. Garbin et al. conducted a study wherein the deterioration of toothbrushes was studied in preschool children. (6) Among the 333 UTB analysed, 58% of the toothbrushes were in adequate condition for utilization (scores 0 and 1), whereas 42% had inadequate bristles for their function (scores 2 and 3); these results were similar to our own. In contrast, Terreri et al. studied toothbrush wear in a daycare facility and reported that 78% of the toothbrushes were not suitable for plaque removal. (7) However, because the studies by Garbin et al. and Terreri et al. were conducted on preschool children while in our study the participants were university students, the relevance of their findings to the outcome of our research is limited.

This study examined the relationship between toothbrush bristle wear and the period of toothbrush use (in months) in a population of university students. Approximately 56% of the toothbrushes were used for 1 to 3 months and received a score of 0. Even after being used for a period of 4.5 months, toothbrushes were scored at 1 and were still in optimal condition for plaque removal. Rosema et al. conducted a study on the plaque removal efficacy of new and used (3-month-old) toothbrushes. (8) Their study found no difference in plaque removal efficacy of new and 3-month-old UTB. In addition the study concluded that the wear of the bristles is more important than the period of brush use with regards to plaque removal efficacy, which supports the findings of our study. (8) Approximately 38% of the study participants used their toothbrushes for a period of 5 to 9 months, which exceeds the time period of effective toothbrush use as prescribed by the ADA. (3,4) This research finding highlights the need for dental professionals to educate their clients about and reinforce the need to replace toothbrushes after 3 to 4 months of use or after significant wear of the bristles, whichever is earlier. Kreifeldt et al. conducted a study to measure and compare plaque removal efficiencies of different toothbrush designs and used their findings to quantify the loss of plaque removal efficiency of worn toothbrushes, as well as to elucidate the causes. (9) The Kreifeldt et al. study was published in 1980, before the Rawls et al. index for toothbrush bristle wear (1989) was formulated. Kreifeldt et al. used the words "light matting" and "heavy matting" in their study to measure toothbrush bristle wear. The word "matting" used in the Kreifeldt et al. study corresponds to the Rawls et al. index scores of 2 (light matting) and 3 (heavy matting). Kreifeldt et al. recommended that a standard toothbrush be discarded when it shows signs of matting, regardless of age. (9)

Muller-Bolla et al. conducted a study to create a drawing to help adults establish when to replace a toothbrush. (10) Pictures of worn brushing surfaces were generated using an image acquisition system. Images in each study phase were superimposed to provide a single reference outline to indicate when a toothbrush should be replaced. The authors of the study claim to have created a simple drawing that could help adults to determine when they should replace UTB. (10) Information on toothbrush wear as it relates to replacement could easily be added to toothbrush packaging and would be helpful for consumers. It would also be prudent to engage the general public in toothbrush exchange programs during oral health campaigns, wherein guidelines for brush replacement could be reinforced to all participants. Such direct interaction between dental professionals and members of the public offers a clear opportunity for oral health education. During these oral health campaigns, instructions for oral hygiene maintenance were given to the participants by the staff members of the Faculty of Dentistry.

The cleanliness of the toothbrush handle reveals information about the storage condition of those toothbrushes and also the attitudes of the participants. Around 8% of UTB had visible dirt (defined as any unclean matter in brownish colour to black fungal deposits) on more than one-third of the handle. Some of the participants might have submitted their old, dirty toothbrush just to get a free new toothbrush.

Limitations

This study considered time of brushing per session as 2 minutes based on self-reporting by the client. Clients usually overestimate their brushing time. For greater accuracy and validity, this study should have controlled for this variable rather than relying on client self-reports. Powered toothbrush designs have incorporated this understanding by incorporating timers, typically set for 2 minutes, to enable the user to accurately assess their brushing time. However, the efficacy of this feature has not been evaluated. Incorrect brushing technique, excessive pressure applied during brushing, and overestimation or underestimation of the self-reported brushing time by the participants could affect the wear of the toothbrush bristles. This study did not examine these aspects (brushing technique and pressure applied) by the participants which could affect toothbrush bristle wear. Future research studies on toothbrush bristle wear should include these variables.

CONCLUSION

The results of this research study indicate that the replacement of UTB should be primarily based on the amount of wear noticed on the bristles. The general time frame advised of 3 to 4 months can be a secondary factor to be considered, as many individual factors come into play with regards to the splaying of the bristles in the toothbrush.

REFERENCES

(1.) Perry DA. Plaque control for the periodontal patient. In Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's clinical periodontology, 11th ed. St. Louis, MO: Elsevier Saunders; 2012.

(2.) Conforti NJ, Cordero RE, Liebman J, Bowman JP, Putt MS, Kuebler DS, Davidson KR, Cugini M, Warren PR. An investigation into the effect of three months' clinical wear on toothbrush efficacy: Results from two independent studies. J Clin Dent. 2003;14:29-33.

(3.) American Dental Association. ADA Seal of Acceptance Program: Toothbrushes [online]. Available from: http://www.ada.org/en/science-resea rch/ada-seal-of-acceptance/ada-seal- products/produet-category/?supercategory=5.

(4.) American Dental Association. Learn more about toothbrushes [online]. Available from http://www.ada.org/1321.aspx [accessed on 10/04/2014 at 22:00],

(5.) Rawls HR, Mkwayi-Tulloch NJ, Casella R, Cosgrove R. The measurement of toothbrush wear. J Dent Res. 1989;68:1781-85.

(6.) Garbin CA, Garbin AJ, dos Santos KT, de Lourdes Carvalho M, Lima DC. Evaluation of toothbrush bristles' deterioration used by preschool children. IntJ Dent Hyg. 2009;7:285-88.

(7.) Terreri ALM, Saliba CA, Saliba NA, da Silva PR. Evaluation of toothbrush wear and tear in a day care facility. Rev Fac Odontol Lins. 1999;11 (2):42-44.

(8.) Rosema NA, Hennequin-Hoenderdos NL, Versteeg PA, van Palenstein Helderman WH, van der Velden U, van der Weijden GA. Plaque-removing efficacy of new and used manual toothbrushes-a professional brushing study. IntJ Dent Hyg. 2013;11:237-43.

(9.) Kreifeldt JG, Hill PH, Calistl U. A systematic study of the plaque removal efficiency of worn toothbrushes. J Dent Res. 1980;59:2047-55.

(10.) Muller-Bolla M, Lupi-Pegurier L, Bertrand MF, Velly AM. Manual toothbrush wear and consequences on plaque removal. J Clin Dent. 2007;18:73-78.

Kalyan Chakravarthy Gundavarapu *, BDS, MDPH, DDPH (RCS), MBA; Srinivas Sulugodu Ramachandra ([section]), BDS, MDS, FICOI; Daniel Devaprakash Dicksit ([dagger]), BDS, MPH

* Associate professor, Faculty of Dentistry, SEGi University, Selangor, Malaysia

([section]) Senior Lecturer, Faculty of Dentistry, SEGi University, Selangor, Malaysia

([dagger]) Lecturer, Faculty of Dentistry, SEGi University, Selangor, Malaysia

Correspondence to: Dr. Kalyan Chakravarthy Gundavarapu; kalyan@segi.edu.my

Submitted 25 September 2014; revised 16 January and 26 January 2015; accepted 30 January 2015

Table 1. Toothbrush bristle wear index proposed by Rawls et at,
and effectiveness of plaque removal based on the scores

Score   Appearance of          Effectiveness
        toothbrush

0       It is impossible to    In suitable
        state if the           condition for
        toothbrush was used    optimal plaque
        or not                 removal

1       The bristles of the
        toothbrush seem to
        be separated within
        some tufts

2       Most tufts are
        separated, many        Not in suitable
        cover other tufts      condition for
        and present a large    optimal plaque
        number of curved and   removal
        inclined bristles

        Most tufts are
3       covered by other
        bristles and
        bristles are folded
        and tipped

Table 2. Interexaminer Kappa scores for 2 calibrated examiners

                                Examiner KCG
Examiner
SSR            0         1         2         3

0              17        1         0         0         18 (14.9%)
1              1         42        4         0         47 (38.8%)
2              0         9         30        2         41 (33.9%)
3              0         0         0         15        15 (12.4%)
               18        52        34        17        121
               -14.90%   -43.00%   -28.10%   -14.00%

Weighted Kappa = 0.856; Standard error = 0.035; 95% 0=0.788 to 0.924

Table 3. Scoring criteria for visible dirt on toothbrush handle

Score   Criteria for scoring visible dirt on toothbrush handles

0       Toothbrush handle is clean.

1       Visible dirt seen up to one-third of toothbrush handle.

2       Visible dirt seen on more than one-third and less than
        two-thirds of the toothbrush handle.

3       Visible dirt seen on more than two-thirds of
        the toothbrush handle.

Table 4. Frequency and mean number of months used
versus agreed Rawls et alls index score

         Rawls et al.'s index
         agreed score

Number     0 (n=18)        1 (n=52)
of
months      n       %       n       %

1           4     3.3       4     3.3
2           2     1.7      16    13.2
3           9     7.4      32    26.4
4           2     1.7       0     0.0
5           1     0.8       0     0.0
6           0     0.0       0     0.0
7           0     0.0       0     0.0
8           0     0.0       0     0.0
9           0     0.0       0     0.0
Mean     2.67            4.48

                                         Total
         Rawls et al.'s index            toothbrushes
         agreed score                    examined
                                         (n=121)
Number    2 (n=34)          3 (n=17)
of
months      n       %       n       %       n       %

1           0     0.0       0     0.0       8     6.6
2           0     0.0       0     0.0      18    14.9
3           1     0.8       0     0.0      42    34.7
4           5     4.1       0     0.0       7     5.8
5           6     5.0       1     0.8       8     6.6
6          13    10.7       3     2.5      16    13.2
7           4     3.3       8     6.6      12     9.9
8           5     4.1       4     3.3       9     7.4
9           0     0.0       1     0.8       1     0.8
Mean     5.85            7.06
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Title Annotation:ORIGINAL RESEARCH
Author:Gundavarapu, Kalyan Chakravarthy; Ramachandra, Srinivas Sulugodu; Dicksit, Daniel Devaprakash
Publication:Canadian Journal of Dental Hygiene
Article Type:Report
Date:Jun 1, 2015
Words:3509
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