Toothbrush, its Design and Modifications : An Overview

5Intern, J.N.Kapoor DAV (C) Dental College, Yamuna Nagar, Haryana Abstract Tooth brush has been an integral part of a daily routine across many cultures around the world from the times of antiquity to the 21st century. Over the years, several types of toothbrush has been invented. Some of the them are useful for physically and mentally handicapped children The aim of this review article is to describe toothbrush design and various modifications that have been made in the several years.


INTRODUCTION
E ffective plaque control facilitates good gingival and periodontal health, prevents tooth decay and preserves oral health for lifetime. (1) The various methods commonly used for plaque removal include chemical and mechanical methods. Among the various mechanical aids available toothbrushing is the primary and most widely accepted method of plaque removal. (2) Toothbrushing carried out with effective technique and for adequate duration of time has been found to be highly effective measure of plaque control. The design of a toothbrush especially with regard to its size and contour should be such that it aids in mechanical removal of plaque. The efficacy depends on types, design of brush, method of brushing, time taken and also on supervision in care of small children. (3) Over its long history, the toothbrush has evolved to become a scientifically designed tool using modern ergonomic designs and safe and hygienic materials that benefit us all. (4) Due to variety of brushes currently available and constant development of new

Supplementary information
The online version of this article (https://doi.org/10.15520/jcmro.v3i08.32 2) contains supplementary material, which is available to authorized users. brushes ,the dental professional must maintain a high level of knowledge of these products and advise the patients appropriately. (5) Hence this review article emphasizes on tooth brush designs.

DISCUSSION
Among the various mechanical aids available, Toothbrushing is the primary and most widely accepted method of plaque removal(Loe1979). (6) Various tooth brushing methods have been advocated. Each has been designed for specific need of patient as dental and periodontal conditions. The basic fundamentals have not changed since the times of the Egyptians and Babylonians which includes a handle to grip, and a bristle-like feature to clean the teeth. Using modern ergonomic designs and safe and hygienic materials, toothbrush has evolved to become a scientifically designed tool that benefit all of us during its long history. (7) Types of toothbrushes ( 1) Conforms to individual's requirements in size, shape and texture.
2) Be easily and efficiently manipulated.
3) Be readily cleaned and aerated, impervious to moisture. 4) Be durable and inexpensive.

5)
Have prime functional property of flexibility, softness and diameter of bristles or filaments and strength, rigidity and lightness in the handle. 6) Be designed for utility, efficiency and cleanliness.

I) Conventional or manual toothbrush design
The ideal toothbrush design is specified as being user-friendly, removes plaque effectively and has no deleterious soft tissue or hard tissue effects. (9) Conventional manual tooth brush design mainly consists of (10) Head, bristles and handle.

3/8 inches wide
2) Surface area : 2.54-3.2cm 3) Number of rows : 2-4 rows of bristles 4) Number of tufts : 5-12 tufts per row 5) Number of bristles : 80-85 bristles per tuft 1) Head: It is designed for effective cleansing of every tooth surface. Each brush head, is divided into 2 parts: the toe, located at the extreme end of the head, and the heel end closest to the handle. (12) Toothbrush heads are composed of tufts, which are individual bundles of filaments secured in a hole in the toothbrush head. (5) Filaments within the tufts are known as bristles.
Toothbrush heads usually comes in different (8) shapes and sizes. a) Shapes : There are variety of shapes such as rectangular, oblong, oval, almost round and diamond shape.
Every tooth surface can be cleaned effectively with the conventional toothbrush head designs. Diamond shaped toothbrush is convenient for posterior teeth cleaning as its head is narrower than conventional. Round head/oblong shaped head is easier to guide around brackets and wires. (5) CURRENT MEDICAL RESEARCH AND OPINION CMRO 03 (08), 570−578 (2020) b) Size : There are usually three types of head size: medium, large and small. The size of head is usually chosen based on size of the individual's mouth. 13 For adults, large or medium sized heads would be sufficient. Small size heads are recom-mended for children as their teeth and mouth are generally smaller. (5) Based on the size of oral cavity, different sizes of heads are available according to the age. (7) 0-2 years : Brush head size should be approximately the diameter of a Hong Kong 10-cent coin (~15mm)

2-6 years
Brush head size should be approximately the diameter of a Hong Kong 20 -cent coin (~19mm)

6-12 years
Brush head size should be approximately the diameter of a Hong Kong 50 -cent coin (~22mm)

years and above
Brush head size should be approximately the diameter of a Hong Kong one dollar coin (~25mm) Latest toothbrush heads are flexible. The head is splitted into two parts and join together by a rubber portion, so that it bends and curves to follow the curvature of our teeth as we brush. It also helps us to access places which are hard to reach. (13) 2) Bristles : Toothbrush heads are composed of tufts, which are individual bundles of filaments secured in a hole in the toothbrush head. Filaments within the tufts are known as bristles. (14) Bristles are vital because they directly contact the teeth and gum tissue. (15) Bristles usually varies in (16)  Bristle type : Toothbrush bristles ranges from very soft to soft in texture, although harder bristle versions are available. (4) Soft bristle toothbrush are preferred because, Firstly, many people don't follow a proper techinque of toothbrushing, also hard toothbrush bristles cause abrasion of the surface and tend to remove the surface enamel of the tooth. Secondly the gingival damage by hard bristles pull it down towards to root, which leads to sensitivity of the teeth while drinking cold liquids, even water. (17) Pattern (14) The different bristle designs include flat trim, multilevel, wavy design, zigzag design etc. The firmness of a bristle depends on three factors i.e. Materials, diameter and length.

Bristle Shape
Toothbrush bristles with sharp edges (also known as burrs) are more destructive to oral tissues than endrounded bristles. The soft-bristled brushes that are ADA approved are end-rounded. (5) Bristle arrangement Multitufted brushes usually offer assorted bristle sizes and shapes and are engineered for better cleaning. (5) 3) Handle : Handle is that part of the brush from where we hold the brush.The most recent toothbrush models include handles that are straight, angled, curved, and contoured with grips and with soft rubber areas to make them easier to hold, use and control. (4) The handle should provide a good grip to the hand. (17)

II) Powered toothbrush
Mechanical devices were patented in the mid-19th century with the goal of addressing the limitations of manual toothbrushes. (18) Ritsert and Binns and Grossman and Proskin found that an electric toothbrush was more effective in removing plaque than a manual toothbrush when used by children and adolescents (6) The power toothbrush as we recognize it today has its roots in prototypes first commercially available in the 1960's.
With the introduction of the Oral-B Plaque Remover 'D5' and its novel, prophylaxis-inspired oscillatingrotating mode of action, a major milestone in the development timeline of power toothbrushes occurred in 1991. With brush head being cup-shaped and endrounded bristles which provides robust plaque removal with 5600 oscillations per minute, this was the first clinically proven power toothbrush technology which clean teeth better than a manual toothbrush. It also featured new compliance-enhancing features, including a two minute light timer to boost brushing frequency. (18) In 2007, the Oral-B Triumph with Smart Guide was the first power toothbrush with clinically proven combined oscillating/rotating/pulsating technology, alongwith an innovative new wireless remote display feature (Smart Guide) for continuous visible brushing feedback.
Since their debut in the early 1990s, sonic power toothbrushes have continued to evolve. Oral-B introduced a new sonic power brush (Sonic Complete TM ) in 2004 followed by the Pulsonic TM in 2008, targeting consumers who favored sonic brushes but wanted a quieter, slimmer/lighter option with maximum cleaning performance. Most recently, DiamondClean TM by Philips boasts a redesigned handle and high-density, diamond-shaped bristles that should improve cleaning and whitening. (18) Differences in Power Toothbrush Technologies (5,7,18) Three variables which can distinguished commercially available power toothbrushes are : Brush head, Power source, Cleaning technology modality. C) Brush Heads : The small, round brush head is designed to perfectly cup and wrap the tooth surface. Brush heads customized for specific patient desires/ needs has been offered by sonic toothbrush manufacturers.
Basis for Professional Recommendation of Power Toothbrushes (19) There are three key reasons why a power toothbrush is a wise choice. 1) Patient Compliance and Preference : Power toothbrushes overcome these barriers to maintain good oral hygiene through increased self-feedback and ease of use and have been shown to enhance motivation and compliance.
2) Clinical effectiveness : Many current-generation power toothbrushes have shown convincing evidence of efficacy in reducing plaque, gingivitis, stain and calculus in clinical research of varying study designs, lengths and patient populations.
3) Safety : The safety of modern power toothbrushes is not a matter of concern as it has been researched extensively.
The recommendation should be based on clinical effectiveness in plaque, gingivitis, stain, and calculus control and safety, with allowances for patient preference. (20,21) • Rechargeable brushes : Rechargeable brushes have many features which include, cost variation based on the extent of high-tech options to monitor safety, brushing time and ensurance of best brushing experience. Some models (e.g., Oral-B premium brushes).
• Oscillating-Rotating Brushes : An extensive independent review has also concluded that oscillating-rotating power toothbrushes have been shown to be as gentle on teeth and gums as a manual toothbrush.
• Multi-Directional Brushes : This brush was designed for patients who prefer a manual-like brushing experience, but still want better cleaning results than a regular manual or a leading sonic power technology.
CURRENT MEDICAL RESEARCH AND OPINION CMRO 03 (08), 570−578 (2020) • Sonic Brushes : Sonic toothbrushes are widely available, and recent clinical research has shown the effectiveness of sonic power technology in plaque, gingivitis and stain reduction.
• Battery-Powered : These brushes represent the lowest end of the cost spectrum and valued by those seeking a budget-friendly power brush option or who want to test the waters with power toothbrushes with a minimal cost investment.
2) Patient is instructed to spread the dentifrice over several teeth before starting to brush to prevent splashing of the dentifrice.
3) Not turning the power brush on until the brush is in the oral cavity also reduces the spattering of toothpaste.
4) The patient should vary the brush position to reach each tooth surface, including the distal, facial, mesial and lingual surfaces. The angulation may need to be altered for access to malposition teeth. Be sure to instruct the patient to "feel" the toothbrush on all surfaces of the teeth. This will become second nature after a while, so the patient will not have to think about it. Toothbrush is placed with filaments pointing into the occlusal pits at a right angle for brushing the occlusal surfaces. The brush head is moved in a slight circular motion whereas the filaments are in the occlusal pits or can press moderately (not bending the bristles) so the filaments go straight into the pits and fissures. Sharp and quick strokes for the occlusal surfaces. To dislodge any loosened debris, the toothbrush should be lifted after each stroke.

5)
With power toothbrush, tongue cleaning can also be done as it retards plaque formation and total plaque accumulation. For tongue cleaning, some toothbrushes have specific brush head design. With the tongue extruded, the brush head should be placed at a right angle to the midline of the tongue with the bristles pointing toward the throat. The sides of the filaments are drawn forward toward the tip of the tongue. with light pressure. This should be repeated 3-4 times till the tongue surface is clean.

III) Other different types of toothbrushes
1. Proxabrush : The interdental brush is slender, so it is only effective over a small surface area per stroke. These shortcomings call for a specially designed brush, that can remove plaque, easily and efficiently, from the critical surfaces which bound residual ridges in the partially edentulous subject. These brushes are known as proxabrush. Its design facilitates access to proximal surfaces, even as far back as third molars. This brush has the advantage that it carries the head of the brush at right angles to the handle, and it is thus easy to apply to distal and mesial surfaces of posterior teeth. (6) 2. Soladey-2 : A new toothbrush called Soladey 2 ® has been recently introduced and is claimed to have better plaque removing potential than conventional toothbrushes due to a photo-electrochemical effect with incorporation of an Ntype semiconductor of Titanium dioxide (TiO) at the neck of the brush. It is possible that the reported photocatalytic property of the semiconductor may be involved in some way in the observed reduction of plaque (Niwa & Fukuda 1989). (23) 3. The traveler ′ s toothbrush : The current traveler's toothbrush includes a toothbrush that houses toothpaste in a cylindrical handle. It uses a mechanical device consisting of a twist knob attached to a string and rubber gasket.The redesigned toothbrush also includes toothpaste within its handle, but possess an ergonomically shaped handle allowing a comfortable grip while brushing.  11. Musical toothbrushes : De La Rosa suggested that an average child removes only about 50% of the plaque present on teeth. This tooth brush consists of the handle that is available in different animal shape and also when we press the button the music will play for 3 min. When music starts, the child will start the brushing when the music stop the child will stop the brushing. (30) 12. Clinically proven products to meet the needs of patients undergoing more specialised care such as orthodontics, implants and periodontal surgery.
a) Orthodontic Toothbrush: The Orthodontic toothbrush has been developed for safe and effective brushing of teeth fitted with orthodontic appliances including braces, brackets, tubes and wires.
b) Post-Surgical Toothbrush: After oral surgery, it is important that patients keep their mouth clean, especially to help the wound heal uneventfully. The Post-Surgical toothbrush has been designed with those instructions in mind -to help keep the healing wound clean. The post-surgical toothbrush is highly effective in removing dental plaque and food debris near the healing wound and any sutures that kept the wound closed. These brushes are designed to be used until the surgical site is fully healed. c) Denture Toothbrush : It is recommended for the daily care of removable dentures and acrylic retainers. The Denture brush consists of two differently configured brush heads: a flat bristled head for smooth surfaces and a single-tufted head for hardto-reach areas. It is recommended that removable dentures and orthodontic retainers are brushed at least twice a day, especially after meals.

SUMMARY & CONCLUSION
Plaque control is one of the key elements of practice of dentistry. Mechanical plaque removal with tooth brushes remains the primary method of maintaining good oral hygiene. Keeping in mind the main purpose of brushing, any toothbrush with a simple design following ADA specifications, that provides access to all areas of the mouth should be the suitable one, provided the patient uses proper brushing technique. It is certain that for a motivated, well-instructed person with the time and skill, mechanical plaque control measures are sufficient to attain complete dental health. Toothbrushing and interproximal oral hygiene aids proves the optimal method of controlling plaque accumulation, whereas gingivitis can be prevented by daily toothbrushing. Powered toothbrushes are superior to their manual counterparts in their ability to remove plaque from the approximal areas but show equality on the flat or facial surfaces of the teeth. An oral hygiene training program has to be based on risk analysis and tailored to the individual needs by diagnosis, education and training, and needs-related oral hygiene.