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Canadian Journal of Dental Hygiene logoLink to Canadian Journal of Dental Hygiene
. 2024 Jun 1;58(2):81–87.

Evaluation of plaque removal by a single-headed versus a triple-headed manual toothbrush using different plaque assessment tools

Nathalie Vanstraelen *, Mihai Tarce §,‡, Johanna de Almeida Mello Δ, Katleen Vandamme §, Joke Duyck Δ
PMCID: PMC11223639  PMID: 38974826

Abstract

Background:

Dental plaque is a common issue that can be effectively managed with proper oral hygiene practices and regular oral health care. The aim of this crossover study was to assess dental plaque using different methods (digital and clinical plaque scores) and evaluate the effectiveness of toothbrushing with a triple-headed manual toothbrush compared to a single-headed manual toothbrush in removing dental plaque.

Methods:

Plaque staining was performed to assess dental plaque amounts before and after brushing with the triple-headed (test) and single-headed (control) manual toothbrush in 21 study participants after plaque was allowed to accumulate for 48 hours. Dental plaque was scored both clinically as well as digitally.

Results:

Toothbrushing with a manual single-headed toothbrush and a triple-headed toothbrush was found to be equally effective when comparing plaque removal ability. Brushing time was shorter when using a triple-headed toothbrush, compared to a single-headed toothbrush.

Conclusion:

The triple-headed manual toothbrush may be a good alternative to the single-headed manual toothbrush for certain patient groups.

Keywords: crossover design, dental plaque, oral health, oral hygiene, preventive dentistry

PRACTICAL IMPLICATIONS OF THIS RESEARCH.

  • Using advanced digital methods of plaque scoring, a conventional single-headed manual toothbrush and a triple-headed manual toothbrush were found to be equally effective in removing dental plaque.

  • A triple-headed manual toothbrush can be recommended for care-dependent individuals as a good alternative for daily oral care, as it provides a shorter brushing time, which is useful and efficient in health care settings.

INTRODUCTION

Good oral hygiene is essential to prevent diseases in the oral cavity such as caries and periodontitis and hence tooth loss.1-4 It is a prerequisite for good general health and quality of life,5-7 as poor oral hygiene is associated with serious health problems such as aspiration pneumonia.8 In addition, tooth loss as a result of oral pathology due to poor oral hygiene is associated with impaired mastication,9 which is in turn related to an increased risk for cognitive decline and malnutrition10, 11 and subsequent complications. Good oral hygiene is thus a key factor that cannot be neglected in the preservation of good oral and general health. Nevertheless, oral hygiene in care-dependent persons is generally poor.12, 13

Mechanical pla que removal by means of a toothbrush has been shown to be efficient.3 It is, however, often difficult to perform by care-dependent persons due to impaired dexterity or cognition. Oral hygiene performance by caregivers is also challenging. There is therefore a constant search for alternative techniques and materials to facilitate more effective mechanical plaque removal. One of these alternatives is the triple-headed toothbrush14-17 that is designed to brush the occlusal, oral, and buccal surfaces of the tooth simultaneously. This method of toothbrushing is claimed to result in a shorter brushing time, which could be very useful18 for certain patients with limited dexterity who find it difficult to use a conventional single-headed toothbrush. Besides brushing time, the efficiency of plaque removal is another common study variable, traditionally assessed by plaque scoring.16 However, since clinical plaque measurements using various indices have certain limitations, such as the subjectivity of the indices, particularly at the interproximal sites, and intra- and inter-examiner variability,19 additional plaque measurements on digital images have been investigated recently. Earlier studies performed plaque measurements with 2D or 3D imaging techniques, revealing the first evidence that these techniques are valuable.20, 21 It has been shown recently that detecting and monitoring dental plaque levels on 2D images from an intraoral camera and on 3D images from an intraoral scanner and 3D imaging techniques is reliable. Moreover, the plaque values from both 2D and 3D images and the chairside clinical examination were found to be comparable.22

Although previous studies indicate better plaque removing potential of the triple-headed toothbrush as compared with the conventional single-headed toothbrush,23 it is uncertain whether subtle differences in remaining plaque (e.g., on interdental surfaces) can be accurately detected when only clinically assessed by plaque scoring. This study aims to measure plaque digitally using intraoral scans and compare it to the chairside clinical plaque scoring, in order to more precisely evaluate and compare the plaque removal potential of the single- versus triple-headed manual toothbrush.

METHODS

Study population

Twenty-one healthy volunteers participated in this randomized, single-blind, controlled crossover study. A minimum sample size of 20 was chosen, as it was consistent with similar studies where significant results were found.24, 25 Moreover, crossover studies have the advantage of allowing smaller sample sizes, as the within-patient variances are lower than the inter-participant variances.26 Exclusion criteria were an active orthodontic treatment, presence of a removable prosthesis, missing teeth (with exception of the third molars), and pregnancy. Volunteers were dental students at KU Leuven in Belgium. Twenty subjects were righthanded and one subject was lefthanded. All participants had a minimum of 24 natural teeth present with no interposed edentulous spaces.

Study design

A crossover study was designed, allowing both single-headed and triple-headed manual toothbrushes to be used by every subject in the clinical trial (Figure 1). The participants suppressed oral hygiene measures 48 hours prior to each recording to allow a sufficient amount of dental plaque to develop. Toothbrushing and the use of dental floss, interdental brushes and/or mouthwash were not allowed during that period. The choice of a 48-hour plaque build-up was based on the fact that plaque becomes pathogenic after 48 hours.27, 28 This time period was congruent with other similar scientific studies.29-31 Dental plaque was stained using a plaque disclosing solution (GUM Red-Cote™, Sunstar S.A., Etoy, Switzerland), whereafter patients were asked to thoroughly rinse their mouth 4 times with water. The amount of plaque was scored on the buccal and oral side of all upper teeth except the third molars, using the Quigley-Hein Plaque Index (QHI).32 QHI scores the amount of dental plaque on the tooth surface from 0 to 5, with 0 being no plaque present and 5 being more than two-thirds of the tooth surface covered with dental plaque. In addition, an intraoral scan (3Shape Trios® 3, Copenhagen, Denmark) was taken to score the remaining plaque on the digital images (Figure 2). The amount of dental plaque was quantified on the 2D colour images through 2 methods: 1) visual and 2) semi-automated, using MeshLab software (Meshlab, 2016.12).33 All remaining plaque, including interdental plaque if detected, was analysed.

Figure 1.

Figure 1.

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Single-headed and triple-headed toothbrushes

Figure 2.

Figure 2.

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Tooth plaque on the digital images: intraoral scan

Figure 3.

Figure 3.

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Steps taken during the study

The subjects were provided with either a single-headed or a triple-headed manual toothbrush. No brushing instructions were given prior to the experiment, either for the single-headed or the triple-headed toothbrush in order to reproduce a real-life situation. Nevertheless, as participants were dental students, they had received instructions on the modified Bass method when using a single-headed manual toothbrush.34, 35 No specific instructions in the curriculum, however, were given for the triple-headed toothbrush. No toothpaste was used so that the sole influence of mechanical cleaning could be evaluated. The duration of toothbrushing was not predetermined and each subject continued brushing until they considered their teeth to be clean. Brushing time was recorded by the researcher who supervised the experiment. Following toothbrushing and to optimise visualisation, disclosure of remaining plaque was performed. Plaque measurements were taken, both clinically as well as on the images obtained via a second intraoral scan. Thereafter, the teeth were cleaned and polished using Zircate® Prophy Paste (DenstplySirona, Pennsylvania, US). The above protocol (Figure 3) was repeated for each participant after each plaque evaluation session. As this was a crossover study, both toothbrushes were tested once by all participants. The order in which the different toothbrushes were used was randomized. A wash-out period of at least 1 week, during which the standard of oral hygiene care was provided, was respected.

Whereas plaque scoring was performed for all teeth (except third molars) and tooth surfaces, the semi-automated analyses on the intraoral scan were performed on one selected tooth surface per participant and per test condition. Since most plaque accumulated on the buccal surface of the posterior teeth and since toothbrushing is generally poorer on the dominant side36, 37 (right for righthanded persons and left for lefthanded persons), the buccal surface of tooth 17 (n = 20) or 27 (n = 1), depending on the dominant hand of the participant, was selected for the semi-automated analysis. Using Adobe® Photoshop Elements 13 (Adobe Systems, California, US), sites with dental plaque were defined and colour coded. The modified image was subsequently imported into ImageJ/FIJI38 and a colour histogram was generated to determine pixel counts of the tooth and of the dental plaque (Figure 4). Both counts on the images (visual and semi-automated) were combined to determine the percentage of plaque coverage of the tooth prior to and following toothbrushing.

Statistical analysis

Mean and standard deviation were determined for the 3 recorded dental plaque indices: clinical; visual on digital image (for all teeth except third molar); and semi-automated on digital images for teeth 17/27 of the different teeth and tooth surfaces. Plaque scores and plaque reduction were calculated and statistically analysed for the differences between toothbrush types and for the clinical and digital scan. Paired t-tests were used, and statistical significance was set at 5% (p < 0.05). The brushing time was also analysed.

Ethics approval

Approval for the study was obtained from the Institutional Ethics Committee (S61032, University Hospitals Leuven) and informed consent was given by all participating subjects (N = 21). The study was registered in the Belgian Clinical Trials database (Identifier: B322201836347) and was conducted according to the ICH-GCP (International Conference on Harmonization Guidelines on Good Clinical Practice) principles.

RESULTS

A total of 21 students participated in the study. They were between 19 and 26 years of age; 14 of the subjects were female (66.7%).

Results showed great correspondence between clinical and digital plaque reduction scores (Table 1), with almost no significant differences for brushing with the single- versus triple-headed toothbrush types. Digitally, no statistically significant differences in plaque reduction were found for any sites in the mouth when comparing plaque reduction by means of a single-headed versus triple-headed toothbrush (Table 1, Figure 5). Plaque preferentially accumulated on the buccal tooth surfaces, resulting in statistically increased plaque reduction values compared to the oral surfaces (Figure 6). Furthermore, no statistically significant difference was found between the single-headed versus triple-headed toothbrush for plaque reduction on the buccal surfaces of both anterior and posterior teeth. For the oral surfaces, a significantly higher plaque reduction was clinically observed for the posterior oral surface after brushing with the triple-headed toothbrush (p = 0.02) (Figure 6, Table 1). Finally, using either the single- or the triple-headed toothbrush, no significant differences in plaque removal were found between dominant and non-dominant sides. Plaque scores were significantly lower after brushing for both toothbrush types (Table 2), showing that brushing with both types was effective, although the mean plaque reduction was not statistically different between both types (p = 0.22). A significant difference in brushing time between the single-headed (2 min 42 s) versus triple-headed (2 min 22 s) toothbrush was noted.

Figure 4.

Figure 4.

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Modified image imported into ImageJ/FIJI

DISCUSSION

The present study revealed no overall significant difference in plaque removal efficiency between a conventional single-headed and a triple-headed manual toothbrush. This result is in line with previous studies15-17, 23 and suggests that a triple-headed toothbrush can be a valuable alternative to a conventional toothbrush. The findings were obtained through plaque scoring that was performed clinically and on digital images obtained from intraoral scanning of all teeth (except third molars) as well as through semi-automated plaque measurements on digital images of the buccal surfaces of tooth 17 or 27.

Table 1.

Means and standard deviations of plaque reduction with a single-headed versus triple-headed toothbrush, assessed clinically and on digital images obtained from intraoral scanning using the Quigley-Hein Plaque Index

Plaque reduction

Plaque reduction

Single-headed toothbrush

Triple-headed toothbrush

p value

p value

 

 

Clinical

Digital

Clinical

Digital

Clinical

Digital

Total

 

1.42±0.51

1.52±0.47

1.53±0.46

1.50±0.46

0.34

0.87

Buccal

 

2.06±0.67

2.15±0.63

2.12±0.63

2.05±0.63

0.66

0.48

Oral

 

0.75±0.50

0.88±0.42

0.94±0.45

0.96±0.42

0.15

0.50

Posterior

 

1.43±0.50

1.53±0.45

1.61±0.47

1.60±0.47

0.19

0.60

Anterior

 

1.40±0.69

1.51±0.67

1.44±0.68

1.43±0.66

0.81

0.57

Posterior

Oral

0.66±0.45

0.79±0.43

0.98±0.46

0.99±0.46

0.02a

0.12

 

Buccal

2.18±0.72

2.24±0.70

2.24±0.66

2.14±0.65

0.73

0.59

Anterior

Oral

0.92±0.77

0.98±0.68

0.89±0.72

0.92±0.62

0.84

0.67

 

Buccal

1.88±0.82

2.02±0.83

1.98±0.83

1.95±0.84

0.55

0.65

Posterior

Left

1.41±0.52

1.52±0.44

1.50±0.53

1.48±0.51

0.58

0.80

 

Right

1.46±0.58

1.55±0.55

1.71±0.55

1.65±0.51

0.07

0.49
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Anterior: incisors and canines; Posterior: premolars and molars

ap < 0.05

Figure 5.

Figure 5.

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Differences in plaque reduction for the sites in the mouth

This study also aimed to evaluate whether a more accurate assessment, i.e., measuring the percentage of the tooth surface covered by plaque, could reveal different results. Even with a more accurate technique, however, no difference in plaque removal was observed between the 2 toothbrushes.

The plaque removal potential of 2 types of manual toothbrushes were compared in this study, although it is known that manual toothbrushing is less effective than electric toothbrushing. Electric toothbrushing still remains the gold standard for the general patient with sufficient manual dexterity and cognitive abilities.39, 40 Although an electric toothbrush can be used very efficiently by patients with limited dexterity, there is still a large part of the patient population for whom it remains difficult . For people with cognitive disabilities (e.g., people with dementia or with mental disabilities), electric brushing is sometimes difficult because patients do not always accept the device in their mouth and can be confused or feel threatened by it.41, 42 For this reason, a manual toothbrush is often used for the latter group of patients. To increase ease of use for persons with limited dexterity or for caregivers, as well as to reduce brushing time, the manual triple-headed toothbrush seems a solid alternative to a conventional toothbrush. Brushing time was observed to be shorter with a triple-headed toothbrush, which favours the choice of this type of toothbrush for specific groups of patients for whom it is difficult to achieve a sufficiently long brushing time.

The study participants were dental students, who have knowledge of the importance of oral health and practise good oral hygiene. As a result, brushing with both toothbrushes was probably performed using proper technique, thereby revealing the maximum potential of both toothbrushes. However, despite using the p,roper brushing technique, not all accessible areas were observed to be plaque-free. In addition, interdental plaque removal was not sufficient for either toothbrush. This finding reinforces the importance of good interdental cleaning since no toothbrush (manual, electric, single- or triple-headed) is suitable for adequate interdental cleaning.43, 44

Figure 6.

Figure 6.

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Plaque reduction values

Table 2.

Means (%) and standard deviations of the plaque reduction on selected tooth surfaces quantified on digital images

 

Single-headed toothbrush

Triple-headed toothbrush

 &nbsp;
&nbsp;

Mean (%) plaque reduction (p value)

Mean (%) plaque reduction (p value)

p value

Tooth 17/27

25±13% (0.000a)

31±14% (0.000a)

0.22
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ap = 0.000

A study by Kalf-Scholte et al.16 indicated that plaque removal when using a triple-headed toothbrush can vary among participants. More specifically, the results suggested a correlation between tooth morphology and sphericalness and plaque removal efficiency. Elongated teeth, due to gingival recessions caused by periodontitis, constitute an additional factor that could hinder the effective use of the triple-headed toothbrush. Since all subjects who participated in this study had no gingival recessions or periodontal pathology, the effect of such a condition could not be verified. Furthermore, this study was conducted in “best case” settings which cannot be compared with, for example, a nursing home setting. There, brushing with a toothbrush that requires more dexterity will probably be even more difficult, thereby favouring the use of the triple-headed toothbrush.15, 45 In contrast, the above-mentioned study16 suggested that a triple-headed toothbrush may not be as efficient in a nursing home population because gingival recessions are more common in older people, hence hampering adequate cleaning cervically.

As previously known and as confirmed in the present study, plaque levels are generally higher on buccal surfaces compared to oral surfaces. The obtained results of statistically increased plaque reduction values for buccal surfaces compared to the oral surfaces are thereby logical. This result was independent of the toothbrush type used.

It has been shown that dental plaque removal is generally better on the non-dominant side, i.e. left side for righthanded people and right side for lefthanded people, compared to the dominant side.36, 37 However, this difference was not observed in the present study.

This study revealed a good plaque removal ability of the triple-headed toothbrush compared to the single-headed manual toothbrush. The possibility of negative long-term effects on, for example, gingival recession formation caused by incorrect use of this toothbrush or due to inadequate plaque removal in patients with gingival recession could not be verified. A long-term study to assess these and other adverse effects is indicated.

Strengths and limitations

Although the present study had a small number of participants, the techniques used for measuring plaque were more accurate and innovative than the ones used in other standard plaque studies.

CONCLUSION

A conventional single-headed manual toothbrush and a triple-headed manual toothbrush were found to be equally effective in removing dental plaque. The time spent on toothbrushing when using a triple-headed toothbrush was found to be significantly shorter than when using a conventional toothbrush. Interdental cleaning remains an important oral hygiene factor and it is a necessary addition to toothbrushing when using any kind of toothbrush. The results of this study confirmed that the use of a triple-headed manual toothbrush could be a good alternative to a single-headed manual toothbrush.

CONFLICTS OF INTEREST

All authors declare no conflict of interest.

Acknowledgments

The authors thank all the participants of the study for their time and support.

Footnotes

CDHA Research Agenda category: risk assessment and management

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