TOOTH BRUSHING

TECHNIQUES
BY:
AYUSHI AGRAWAL
III rd yr BDS , INDIA
TOOTH
BRUSHES
TOOTH BRUSHES
ØToothbrushes are most widely used oral hygiene
aids for plaque control
ØAcc. to ADA council
“ The toothbrush is designed primarily to
promote cleanliness of teeth & oral cavity”
ØAdult Toothbrush length: 15 to 19 cm ( 6 to 7.5
inch)
ØLength of brushing plane: 25.4 to 31.8 mm
ØWidth of brushing plane: 7.9 to 9.5 mm
ØBristle & filament height: 11mm
ØParts of Toothbrush
2. HANDLE
3. HEAD
4. TUFTS
5. BRUSHING PLANE
6. SHANK
I. HANDLE :
• That part which is grasped in hand during
tooth brushing.
• Composition is single type of plastic or a
combination of polymers.
• A handle of larger diameter may be
useful for the patient with limited
dexterity such as children, aging patient
& those of any age with disability.
• Straight handles are more common.
Handles with contra-angle provide better
sense of touch
II. HEAD
• The working end of the
toothbrush that holds the
bristles or filaments.
• It should be small enough for
max. maneuverability in oral
cavity.
• Length of brush head: 5-12 tufts
• Width of brush head: 3-4 rows
III. TUFTS
• Cluster of bristles or filaments secured
in head
• Toothbrush BRISTLES

Hard , soft Natural

Medium Multitufted & synthetic
& space tufted
Comparison of Natural & Synthetic
bristles
IV. BRUSHING PLANE
• The surface formed by the free ends of the
bristles or filaments
• Length: Range from filaments of equal
length (flat plane) to those variable length.
• There are variously shaped filament profile
like flat, rippled, dome, multilevel, angled
etc.
• Brushing plane is commonly soft and
rounded for safety to oral soft tissues & tooth
structure.
• ADA specification of toothbrush brushing
surface:- length: 1-1.2 inch, width: 7.9-9.5
V.SHANK
The section that connects head and
handle.
ØTypes of Toothbrushes

MANUAL IONIC
POWERED

SONIC &
ULTRASONIC
I. MANUAL TOOTHBRUSH
The ideal characteristics for a manual
toothbrush can be listed as follows:
c. Should confirm individual patient
requirement in size, shape & texture.
d. Be easily& effectively manipulated
e. Be readily cleaned & aerated.
f. Be impervious to moisture.
g. Durable& inexpensive.
h. Designed for utility efficiency &
cleanliness.
II. POWERED
TOOTHBRUSH
• Also known as Automatic,
Mechanical or Electric toothbrush.
• The powered toothbrush was first
designed in 1885 by Fredrick
Tonberg & first made in 1939.
• PRINCIPLE: The head of
toothbrush oscillate in a side to side
motion or in rotary motion. The
frequency of oscillation is around 40
Hz.
• INDICATIONS FOR POWERED
TOOTHBRUSH:-
2. Young children
3. Handicapped patient
4. Individuals lacking manual dexterity
5. Patient with prosthodontic or endosseus
implants.
6. Orthodontic patient.
7. Institutionalized patient including the elderly
who are dependent on care providers.
8. Patient on supportive periodontal therapy.
•ADVANTAGES OF POWERED
TOOTHBRUSH:-
2. It increases patient motivation resulting in
better patient compliance.
3. Increased accessibility in the interproximal &
lingual tooth surface.
4. No specific brushing technique
required.
5. Uses less brushing force than
manual toothbrush.
6. Brushing timer is incorporated
in some brushes to help the patient
in brushing for required duration.
III. SONIC AND ULTRASONIC
TOOTHBRUSH
• PRINCIPLE:
These types of toothbrushes
produce high frequency
vibration(1.6MHz) .
• ADVANTAGE:
This phenomenon aids in stain
removal as well as disruption of
bacteria cell wall.
• DISADVANTAGE:
It leads to cavitation & acoustic
IV. IONIC TOOTHBRUSH
• They change the charge of a tooth by
an influx of positively charged ions.
• The plaque with similar charge is thus
repelled from the tooth surface & is
attracted by negatively
charged bristles have to
be carried out to prove
the efficacy of these
type of toothbrushes.
TOOTH BRUSHING
OBJECTIVES OF
TOOTHBRUSHING
1) To clean teeth & interdental spaces of
food remnant debris & stain.
2) To prevent plaque formation.
3) To disturb & remove plaque.
4) To stimulate & massage gingival
tissue.
5) To clean tongue.
 TOOTH BRUSHING

IN CHILD IN
& ADOLESCENT ADULT
(0 to19 yrs) (19 yrs &
above)
Tooth brushing in
Child & Adolescent
Various methods of removal of plaque
in child & adolescent are :-
4) TOOTHBRUSH
• Synthetic(nylon) manual toothbrush is the
most commonly used.
• Soft brushes are most preferred in
pedodontics due to decreased chances of
gingival tissue trauma & increased
interproximal cleaning ability.
•Round type of bristles is of choice because it is
associated with lower incidence of gingival tissue
irritation.
•Toothbrush shd also have smaller head & thicker
handle to aid access to oral cavity &
facilitate better child grip.
4) FLOSS
• Interproximal removal of plaque beyond tooth
brushing is necessary which is done by
interdental brushes, floss holders & floss &
end tuft brushes.
•Nylon & Teflon floss are available. Teflon
has advantage that it has lower coefficient
of friction than nylon, this floss also does
not shred & slides easily between tight
contacts.
•Unwaxed nylon filament floss has
generally been considered as floss
of choice as it has an ease of passing
b/w the tight junctions ,lack of wax residue,
increased surface contact & greater plaque
removal.
•In pedodontics, flavored wax floss
may be most effective. Floss-holder
•For orthodontic patient super floss or floss
threader is helpful.

7) DENTRIFRICES
• Dentifrices are used as:-
g) Plaque removing agents abrasives and
h) Stain removing agents surfactants
i) Tartar control properties pyrophosphates
j) Anticaries property
k) Desensitizing property fluoride
•The child dentifrices should contain
fluoride, rank low in abrasives & carry ADA
seal of acceptance.
•The caries preventive efficacy of fluoride
toothpastes in children has been good but
these fluoride toothpaste has an adverse
effect on the child by increasing the total
fluoride intake.
• The use of much of toothpaste may lead
to ingestion of fluoride which is a substantial
source of systemic fluoride for children
at risk of dental fluorosis.
•To reduce chance of dental fluorosis
children:
b) Manufacturers shd market low fluoride
toothpaste for infants or reduce
diameter of tube orifice.
c) Shd advice to use a fluoride
dentifrice in a child older 36months.
d) To use small, pea sized quantity
toothpaste.
• The manufacture shd state that it shd be
non abrasive, non foaming, without
fluoride,safe for infants & ideal for
babies 4mth -3yr. It contain mild
4) DISCLOSING AGENT
• A disclosing agent is a preparation
in liquid, tablet or lozenges form that
contains dye or other coloring agent.
• The bacterial plaque is usually colorless &
after the use of disclosing agents it picks up
color of the agent where as dye is rinsed off
easily from plaque free areas.
• Use:
e) Personalized patient instruction in
location of soft deposits and techniques for
removal.
f) Self evaluation of patient on daily basis.
c) Continuing evaluation of the
effectiveness of the instructions for the
patient to determine need for revisions
of plaque control procedures.
d) Preparation of plaque index.
e) To gain new information about the
incidence & formation of deposits on the
teeth.
• Method of application:
The patient chews the tablet moves it
around for 30-60 seconds rinse it
completely.
5) CHEMOTHERAPEUTIC PLAQUE
CONTROL
• Chemicals interfere at various stages of
development of plaque:-
c) Micro- org. for plaque formation may be reduced or
eliminated in number.
d) The formation of bacterial & salivary products which
constitute the intermicrobial substance in plaque is
inhibited.
e) Established plaques may be dissolved.
f) Calcification of plaque may be counteracted.
g) Colonization of bacteria on the tooth surface may
be inhibited.
h) Pathogenicity of plaque may be reduced by
interference with metabolisation of plaque bacteria.
6) TOOTH BRUSHING
TECHNIQUE
• There are predominantly 4 main tooth
brushing technique that is described by
Anaise, for children of 11 to 14 yrs old:
c) ROLL METHOD
• The brush is placed in vestibule, the bristle
ends directed apically with the sides of
bristles touching the gingival tissue.
• The patient exerts lateral pressure with sides
of bristles & brush is moved occlusally.
• The brush is placed again high in the
vestibule & the rolling motion is repeated.
• lingual surface same manner with 2 teeth
b) CHARTERS METHOD
• The bristles are placed in contact
with enamel of teeth & gingiva.
• The bristles are placed at 45-
degree angle towards plane of
occlusion.
• A lateral downward pressure is then
placed on the brush & the brush is
then vibrated gently back and forth a
mm or so.
c) MODIFIED STILLMAN METHOD
• This method combines a vibratory action of
bristles with stroke movement of brush in
long axis of teeth
• The brush is placed at mucogingival line, with
bristles pointed away from the crown, &
moved with stroking motion along the gingiva
& tooth surface.
• The handle is rotated toward the crown &
vibrated as brush is moved.
d) HORIZONTAL SCRUBBING
METHOD
• The brush is placed horizontally on buccal & lingual
surfaces
• Then brush is moved back & forth with a scrubbing
motion.
• Anaise concluded that horizontal scrubbing
method exhibited a more significant plaque
removing effect than the roll, charters & modified
stillmans.
• As this method removes more of plaque as
compared to other techniques and it is most
naturally adopted by children so the HORIZONTAL
SCRUBBING TECHNIQUE is the MOST
RECOMMENDED brushing technique for
CHILDREN.
7) FLOSSING TECHNIQUE

1. A 18-24 inch length of floss is 2. Thumb & index fingers are used to
obtained & ends are wrapped guide the floss b/w the 2 teeth to be
around the fingers. cleaned.

3. Care shd be taken not to snap the 4. Floss is then manipulated into “c”- shape
floss around each teeth individually & moved
down thru the interproximal cervical-occlusal reciprocating motion
contacts to avoid gingival trauma. until the plaque is removed.
 AGE – SPECIFIC
INSTRUCTIONS
II. INFANTS (0 TO 1 yr)
• The plaque removal activities should
begin on eruption of the first primary
tooth.
• There shd be cleaning & massaging of gums
before eruption of teeth to help establishing
a healthy oral flora & to aid teething. This
shd be done totally by the parent. Tooth
brush can also be used if parent feel
comfortable.
• This cleaning and massaging of gums can
be done by wrapping a moistened gauze
•While massaging the child can be placed in
numerous ways, but ARM- CRADLING
POSITION is the simplest & provides the infant
more security. In this the child is cradled with one
arm while massaging is done with the other. This
procedure shd be practiced
once daily.
•Nonflouridated tooth &
gum cleanser may be used.
•The child's first visit to
dentist shd be during this
period.
•Dentifrice is not advised to be used becoz the
foaming action of the paste is objectionable.
II. TODDLERS(1 TO 3 yr old)
• Introduction of moistened, soft–bristled, child
or infant sized TOOTH BRUSH into plaque
removing procedure.
• Only a non-fluoridated dentifrice shd be
used.
• Positioning of child and parent is again
important in this case. several positions can
be used by the parent but LAP TO LAP
POSITION is most common
& allows one adult to
control child's
movements while
the other adult
III. PRESCHOOLERS (3 TO 6 yrs
old)
• The parents shd continue to brush the
teeth for the child.
• A fluoride dentifrice can be introduced at 3 yrs of
age. Only pea sized amount of toothpaste shd be
used.
• Flossing is also started in this age. In the primary
dentition , posterior contacts are the only areas
where flossing is needed.
• In this age the position can be such that the parent
stands behind the child and both face the same
direction. The child rests his or her head back in
parents non- dominant arm. With the hand of this
arm the cheeks can be retracted& the other hand is
used for brushing . This position is also appropriate
IV. SCHOOL-AGED CHILDREN(6-
12yr)
• Most of children can provide their basic oral
hygiene i.e. brushing & flossing under active
supervision by parents.
• Parents can check the cleanliness of
child’s teeth by use of disclosing agent.
after the child has brushed, flossed &
used disclosing agent, the parent can easily
visualize the remaining plaque & assist the child to
remove it.
• Use of fluoridated dentifrices is essential &
fluoridated gels & rinses used in children at risk for
caries.
• Early T/t of malocclusion in this age group.
• This age is at high risk of caries & periodontal
V. ADOLESCENT(12-19yr old)
• At this age the patient has developed adequate
skills for oral hygiene procedures but
compliance is major problem at this age.
• Motivating an adolescent to assume responsibility
for personal oral hygiene may lead to rebellious
rxns.
• These patients are at a risk for caries & gingival
inflammation bcoz of poor dietary habits, pubertal
hormonal changes & poor plaque control habits
due to increase in self-esteem.
• Increasing adolescents knowledge regarding
plaque control & oral diseases, as well as
appealing to their appearance, may also help in
motivating these patients.
Tooth Brushing
In Adults
I. TOOTHBRUSHES
B. TOOTH BRUSHING
TECHNIQUES
3. The Bass method or Sulcus cleaning
method
4. Modified bass method
5. Modified Stillman’s method
6. Charter’s method
7. Scrub brush method
8. The Roll technique
9. Fones method or Circular scrub
method
I. BASS/SULCUS CLEANING
METHOD
Most widely accepted & most
effective method for dental plaque
removal, adjacent & directly beneath
the gingival margin.
INDICATIONS:
d. For all patients for dental plaque removal
adjacent to & directly beneath gingival
margin.
e. Particularly adaptable for open interproximal
areas, cervical areas beneath the height of
contour of enamel& exposed surfaces
f. For routine patients with or without
1. Place the brush at a 45 angle 2. Brush the outer surfaces of each tooth,
against the tooth, making certain upper & lower , keeping the bristles
that the bristles are at gingival against the gingival margin . Repeat
margin. Gently brush the surface the same method on the inner surface
of each tooth using a short, of the teeth as well.
gentle vibratory back & forth
motion.

3. To clean the inside surfaces 4. Scrub the chewing surfaces of the

of the front teeth , tilt the teeth using a short back & forth
brush vertically & make movement. Brushing the tongue
several gentle up and down will remove bacteria & freshen your
strokes using the front half breath.
of brush.
 ADVANTAGES:
b. Effective method for subgingival
cleansing.
c. Provides good gingival stimulation.
d. Easy to learn.
e. Recommended for routine patients with
or without periodontal involvement.

DISADVANTAGE:
h. Time consuming
i. Dexterity requirement is too high
in some patients.
II. MODIFIED BASS TECHNIQUE
INDICATIONS:
c. As a routine oral hygiene measure.
d. Intrasulcular cleaning.

TECHNIQUE:
g. The toothbrush is held such that the bristles
are at a 45- degree angle at gingiva.
h. Bristles are gently vibrated back & forth
motion i.e. vibratory horizontal motion.
i. In a single motion, the bristles are then
swept vertically over the sides of teeth
towards their occlusal surfaces.
 ADVANTAGES:
c. Excellent sulcus cleaning.
d. Good interproximal & supragingival
cleaning.
e. Good gingival stimulation.

DISADVANTAGES:
h. Moderate dexterity of wrist is required.
III. MODIFIED STILLMANS
TECHNIQUE
INDICATIONS:
c. Dental plaque removal from cervical
areas below the height of contour of
enamel & from exposed proximal
surfaces.
d. General application for cleaning tooth
surfaces and massage of the gingiva.
e. Recommended for cleaning in areas
with progressing gingival recession &
root exposure to prevent abrasive
tissue destruction.
 TECHNIQUE:
b. Place the toothbrush at 45 degree angle
partly on gingiva & partly on cervix of
teeth.
c. The bristles are gently moved with a
vibratory pulsating motion& gently swept
occlusally over sides of teeth.
ADVANTAGE:
e. Helps in supragingival cleaning.
DISADVANTAGE:
g. Time consuming.
h. Improper brushing can damage the
epithelial attachment.
IV. CHARTERS METHOD

INDICATIONS:
d. Indications having open inter dental spaces
with missing papilla & exposed root
surfaces.
g. Those wearing FPD or orthodontic
appliances.
h. For patients who have had periodontal
surgery.
i. Patients with moderate gingival recession
particularly interproximally.
j. Massage & stimulation for marginal &
interdental gingiva.
IV. TECHNIQUE:
b. The bristles are placed at a 90 degree angle to the
tooth.
c. The bristles are then moved in a circular vibratory
motion.
ADVANTAGE:
e. Gingival stimulation.
f. Interproximal cleansing.
DISADVANTAGE:
h. Brushing ends do not engage the gingival sulcus to
remove subgingival bacterial accumulation.
i. In some areas the correct brush placement is
limited or impossible, therefore modifications
become necessary which add to the complexity of
the procedure.
j. Requirements in digital dexterity are high.
V. SCRUB BRUSH METHOD
TECHNIQUE:
c. The brush is kept in 90 degree angle to
the tooth.
d. The bristles are moved in horizontal
strokes.
ADVANTAGE:
f. Supragingival cleansing.
DISADVANTAGE :
h. Ineffective at plaque removal.
i. Tooth abrasion & gingival recession.
j. Detrimental to general oral health.
VI. THE ROLL TECHNIQUE
Ø In patients with anatomically normal gingiva
Indications:
d. Children & adult patients with limited
dexterity.
e. Patients required gingival massage &
stimulation.
f. Cleaning gingiva & removal of plaque,
material alba & food debris from the teeth
without emphasis on gingival sulcus.
g. For general cleaning in conjunction with the
use of vibratory technique.
h. Used as a preparatory instruction for
modified stillmans technique.
 TECHNIQUE:
b. Bristles are placed at a 45 degree angle to
tooth surface.
c. Bristles are lightly rolled across the tooth
surface towards the occlusal surfaces.
DISADVANTAGE:
e. Brushing too high during initial placement
can lacerate the alveolar mucosa.
f. Tendency to use quick, sweeping strokes
resulting in no brushing for the cervical third
of tooth & the interproximal area.
g. Replacing the brush with filament tips
directed into the gingiva may produce
punctuate lesions.
VII. FONES METHOD
INDICATION:
Indicated for young patients who want to
do brushing, but do not have the muscle
development for techniques which requires
more co-ordinations.
Ø TECHNIQUE:
e. The child is used to make big circles in air
which are then reduced in diameter very
small circles are made in front of mouth
f. The brush is placed in 90 degree angle to
the tooth & then bristles are moved in
horizontal direction.
 ADVANTAGES:
b. This technique has equal or better potential than
bass technique for plaque removal & prevention of
gingivitis.
c. It is easy to learn.
d. Shorter time
e. Physically or emotionally, handicapped individuals.
f. Patients who lack dexterity for a more technical
brushing method.
g. Gingiva is provided with good stimulation.

DISADVANTAGE:
j. Possible trauma to gingiva.
k. Interdental areas are not properly cleaned.
l. This technique may cause harm to adults
especially who use the brush vigorously.
TOOTH BRUSHING METHODS

CONTINUED…….
B. EFFECTS OF IMPROPER TOOTH
BRUSHING
II. Toothbrush trauma: gingival alterations

Acute alteration Chronic alteration

f. ACUTE ALTERATION(LACERATIONS)
7. Scuffled epithelial border with denuded underlying
connective tissue.
8. Punctate lesions that occur as red pinpoint spot.
9. Diffuse redness && denuded attached gingiva.
PRECIPITATING FACTORS:
11. Horizontal or vertical scrubbing tooth brushing method with
pressure (either manual or powered)
2. Over vigorous placement & application of toothbrush.
3. Penetration of gingiva by filament ends.
4. Use of toothbrush with frayed , broken bristles or filaments.
5. Application of filaments beyond attached gingiva.

g. CHRONIC ULCERATIONS
7. Usually appear on the facial gingiva becoz of the vigor with
which toothbrush is used.
8. Areas most commonly involved are around canines or teeth in
labio- or bucco- version.

• RECESSION
11. Appearance: margin of the gingiva has receded towards the
apex & cementum is exposed.
12. Predisposing anatomic factors
xiii. Malposition of teeth.
xiv. Narrow band of attached gingiva cannot withstand pressures
of brushing
• CHANGES IN GINGIVAL CONTOUR
2. Rolled, bulbous, hard firm marginal gingiva in ‘piled up’ or
festoon shape.
3. Gingival cleft.
PRECIPITATING FACTORS
5. Repeated use of vigorous rotary, vertical or horizontal tooth
brushing techniques over a long period of time.
6. Use of long, brisk strokes with excessive pressure over a long
period of time.
7. Habitual prolonged brushing in one area.
8. Excessive pressure applied with worn out non-resilient brush.

Suggested corrective measures

• Use of softer toothbrush.
• Demonstration of proper brushing technique.
II. Abrasion of teeth
DEF: Abrasion is loss of tooth substance produced by
mechanical wear other than by mastication, or it may be
defined as pathologic wearing away of tooth substance
through some abnormal mechanical process.

CONTRIBUTING FACTORS
v. Hard toothbrush.
vi. Horizontal brushing
vii. Excessive pressure during brushing.
viii. Abrasive agent in the dentifrice.
ix. Prominence of tooth surface labially or bucally.

LOCATION OF ABRADED AREAS

xii. Facial surfaces of canine, premolars & first molars or any
tooth in bucco- or labio version.
xiii. Most abraded area cervical areas of exposed root
surface.
APPEARANCE
Saucer shaped or wedge shaped indentations with smooth shiny
surfaces

CORRECTIVE MEASURES
v. Advise a specific brush with soft textured bristles or filaments.
vi. Change the tooth brushing technique.
vii. Recommend a less abrasive dentifrice.
viii. Use a smaller amount of dentifrice.

L. MAINTAINENCE OF TOOTHBRUSH
• As toothbrushes are vehicle in breeding & transmitting various
organisms so advised cleaning with antiseptic mouthwash.
• Store in dry areas as wet areas may allow bacterial
proliferation.
• Toothbrush shd be kept in open air with head in upright
position with no contact with other brushes.
• Toothbrush has an avg. lifespan of 3 to 6 months.
II. INTERDENTAL CLEANING AIDS
• The toothbrush is not adequate for interproximal
cleaning.
C. DENTAL FLOSS
Dental floss is available in forms:
• Multifilament – twisted / non twisted
• Bonded / non bonded
• Thick / thin
• Waxed / non waxed
Unwaxed dental floss is better than waxed bcoz:
x. Small diameter & pass easily thru tight
interproximal contact.
xi. Under tension it flattens on tooth surface.
xii. Unwaxed floss makes a squeaking noise & this can
be used to monitor performance.
•Interproximal / Interdental brushes
•Powered interdental brushes
CLASSIFICATION OF FLOSS ON BASIS OF
GINGIVAL EMBRASURES
III. TONGUE SCRAPING
• The process of removing debris from surface of
tongue with some form of scraper designed for this
purpose.
• Most tongue scrapers are made of soft flexible
plastic.
TECHNIQUES:
5. BRUSHING
f. Place sides of the brush on the dorsum of the
tongue with the tip directed towards the throat.
g. Apply light pressure & move the brush forward &
out, repeat to cover the entire surface.
9. TONGUE CLEANING DEVICES
i. Device is placed towards the back of tongue on the
dorsal surface, the pulled forward with light
pressure.
IV. IRRIGATION DEVICES
• Valuable in removing the unattached plaque &
debris.
• Mainly composed of a pump & a reservoir
• These devices are used to deliver antimicrobial
agents eg:chlorhexidine.

X. CHEMICAL PLAQUE CONTROL

• Ideal adjunct to mechanical plaque control
specially in individuals with a defective host
defence mechanism, mentally or physically
handicapped & in patients who have undergone
surgical procedures postoperatively.
REFRENCES:-
2. SOBEN PETER
3. JOSEPH JOHN
4. CARRENZA
5. Textbook of periodontology- WILKINS
6. Textbook of child & adolescent-
MCDONALD.
THANK YOU