A Comparative Study on the Efficacy of Plaque Removal Using Conventional Toothbrushes, Bamboo Toothbrushes, and Neem Toothbrushes among School-going Children

Abstract

Introduction

There are many novel toothbrushes available in the market today. The most sustainable option among natural toothbrushes like bamboo toothbrush, neem toothbrush, etc., when compared to the plastic toothbrush, bamboo and neem toothbrushes are biodegradable and can reduce the plastic waste.

Aim

The aim of this study is to assess the efficacy of plaque removal using conventional toothbrush, bamboo toothbrush, and neem toothbrush.

Materials and methods

A randomized, parallel study was conducted among 150 schoolchildren, aged 6–12 years, for a period of 3 months. Three types of toothbrushes were used—plastic toothbrush, bamboo toothbrush, and neem toothbrush. Follow-up was taken at 1 month and 3 months.

Results

In this study, the average plaque scores were as follows: for group A, they were 1.55 ± 0.51 before the operation, 0.66 ± 0.44 after 1 month, and 0.55 ± 0.40 after 3 months. Group B had preop scores of 1.63 ± 0.44, which dropped to 0.55 ± 0.6 after 1 month and 0.48 ± 0.5 after 3 months. Group C's preop plaque scores were 0.92 ± 0.59, decreasing to 0.39 ± 0.44 at 1 month and 0.30 ± 0.4 at 3 months. The p-value for all three groups was 0.001, indicating statistical significance, as it is below the 0.05 threshold.

Conclusion

Natural toothbrushes are equally effective as conventional toothbrushes for plaque removal, are ecofriendly, and biodegradable. Natural toothbrushes can be used as an alternative to plastic toothbrushes. However, additional studies would be required in order to implement these results.

How to cite this article

Ranwa S, Manohar B, Patel R, et al. A Comparative Study on the Efficacy of Plaque Removal Using Conventional Toothbrushes, Bamboo Toothbrushes, and Neem Toothbrushes among School-going Children. Int J Clin Pediatr Dent 2025;18(4):420–424.

Introduction

Dental plaque consists of a community of microorganisms adhering to tooth surfaces in a biofilm, surrounded by a matrix of polymers originating from both the host and bacteria. An important clinical consideration is that biofilms are less responsive to antimicrobial treatments, and the microbial communities within them can exhibit increased pathogenicity through synergistic interactions.¹

Plaque consists of soft, shapeless granular deposits that gather on the surface of teeth, dental restorations, and dental calculus.² According to the WHO (1978), plaque is a unique but highly varied formation resulting from the colonization and growth of microorganisms on the tooth surface. It is made up of various microbial species and their byproducts, all embedded in an extracellular matrix.³

There are two main types of effective plaque control techniques: mechanical and chemical. Effective toothbrushing represents the most straightforward and cost-effective approach to preserving oral hygiene.⁴ Types of toothbrushes used, suitable design of toothbrush, appropriate brushing technique, and proper brushing duration are key factors for plaque control to be highly effective.⁵ Numerous herbal formulations are currently available regarding the composition of toothpaste used during brushing. Similarly, advancements are being made in the types of toothbrushes used for cleaning, potentially allowing for the integration of a natural antibiofilm effect.⁶

Ancient Indian practices involve using ridge gourd fibers, coconut fibers, and bamboo fibers. The bamboo and neem toothbrush features a handle crafted from bamboo to neem, with bristles made from horse mane and fully recyclable nylon. This bamboo toothbrush is environmentally friendly and biodegradable, breaking down naturally when discarded. Natural toothbrushes offer several benefits, including their antibacterial properties, anti-inflammatory effects, abrasive qualities, and notable ability to inhibit plaque build-up.⁶

A straightforward yet efficient way to control plaque mechanically could involve using natural toothbrushes, such as those made from bamboo, neem, and similar materials. Bamboo, a large grass species and a nonwood forest resource, is utilized for producing a variety of goods.⁷ Bamboo toothbrushes are frequently packaged in materials made from recycled products. After paper items are recycled, they are processed and transformed into a different type of cardboard.^8,9 The primary goal of this study is to compare the plaque removal effectiveness of natural toothbrushes with conventional plastic toothbrushes and to evaluate the potential of natural toothbrushes as an alternative option.

Materials and Methods

Trial Design and Participants

This randomized control study investigated the comparative efficacy of plaque removal using a conventional, bamboo, and neem toothbrushes among school-aged children. A total of 150 children, aged 6–12 years, were selected randomly from the Department of Pediatric and Preventive Dentistry, Jaipur Dental College.

Intervention

Participants who provided written informed consent included all individuals aged 6–12 years in this study. The individuals were divided into three groups (50 samples each) (Fig. 1A):

Figs 1A and B:

(A) Plastic, bamboo, and neem toothbrush and Colgate toothpaste; (B) Disclosing agent and Williams probe

• Group A: Conventional toothbrush (plastic toothbrush).

• Group B: Bamboo toothbrush.

• Group C: Neem toothbrush.

The participants were given identical brands of toothpaste to use throughout the study. They received instructions on proper brushing techniques and were instructed to brush their teeth twice daily, in the morning and at night, for 2–4 minutes each time. The prebrushing plaque scores were calculated using Turesky's modification of the Quigley–Hein plaque index (PI) (Fig. 2). Monthly follow-ups and 3-month follow-ups were taken, and the PI was calculated for central incisors. These patients were instructed not to brush their teeth for 24 hours before attending the practice. The rationale for this was to ensure that they had a reasonable baseline of plaque present on their teeth. They did not have to be the same, as we measured the change in plaque score. On arrival at the practice, a plaque-disclosing agent (Fig. 1B) was used prior to toothbrush, and the plaque score was recorded.

Fig. 2:

Turesky's modification of the Quigely–Hein PI

Outcome

A repeated measures ANOVA was conducted to compare the scores across different brushes. To analyze the PI changes for each toothbrush, a paired sample t-test was used at the end of 3 months. All individuals were asked to fill out a questionnaire form to check patients' satisfaction with their allotted toothbrush.

Sample Size

Each group included 50 participants. The sample size was calculated according to the literature and with the help of G*Power software.

Randomization

A total of 150 children who visited the Pediatric and Preventive Dentistry Department at Jaipur Dental College were screened. These children were then randomly divided into three groups: group A (conventional toothbrush), group B (bamboo toothbrush), and group C (neem toothbrush). This study utilized a single-blinding randomized controlled trial design, with group A serving as the control group and groups B and C as the experimental groups. Participants who declined to provide informed consent, those who had received oral prophylaxis within the previous 3 months, and individuals undergoing orthodontic treatment or wearing fixed orthodontic retainers were excluded from the study.

Statistical Methods

A repeated measures ANOVA was performed to compare the scores among the different toothbrush types. To analyze the changes in the PI for each type of toothbrush, paired sample t-tests were utilized. The significance level for all statistical analyses in this study was set at p < 0.05.

Results

In this study, 150 children were enrolled and divided into three groups. The average age of the study subjects was recorded as 7.68 ± 1.55 years. The PI for each child was measured on the 1st day, after 1 month, and after 3 months (Fig. 3). The plaque indices were compared across the three groups to assess their effectiveness in plaque removal. Additionally, a questionnaire was distributed at the end of the 3 months to gauge the participants’ satisfaction with their assigned toothbrushes. The plaque scores were assessed at 1 and 3 months (Table 1). By the end of 3 months, there was a significant reduction in plaque scores across all three groups (p < 0.001). Comparative analysis among groups A, B, and C (Table 1) showed no significant differences in plaque scores, indicating that all three toothbrushes were equally effective in plaque removal.

Figs 3A to I:

PI recorded using disclosing agent, for group A (A to C), prebrushing, 1-month follow-up, and 3-month follow-up, for group B (D to F), preop, 1-month follow-up, and 3-month follow-up, and for group C (G to I), preop, 1-month, and 3-month follow-up

Table 1:

Comparison of mean PI score before and after treatment for each of the brushes

Mean ± SD	Preop	1-month follow-up	3-month follow-up	p-value
Group A	1.55 ± 0.51	0.66 ± 0.44	0.55 ± 0.40	<0.001
Group B	1.63 ± 0.44	0.55 ± 0.6	0.48 ± 0.5	<0.001
Group C	0.92 ± 0.59	0.39 ± 0.44	0.30 ± 0.4	<0.001

Additionally, based on a questionnaire (Table 2), parents were asked about their children's use of interdental aids. In group A, seven children used interdental aids; in group B, five children; and in group C, only two children used them. None of the three groups experienced bleeding while brushing their teeth with their assigned toothbrushes. Patients were also asked about the ease of use of their assigned toothbrushes. In group A, only one participant was dissatisfied, while in groups B and C, two participants from each group expressed dissatisfaction with their toothbrushes.

Table 2:

At the end of the 3-month period, all participants were asked to complete a questionnaire to assess their satisfaction with the toothbrush they were assigned

	Group A		Group B		Group C
Question	Yes	No	Yes	No	Yes	No
Do you have the practice of using any interdental aids?	7	43	5	45	2	48
Did you experience any gingival (gum) bleeding while brushing prior to start of study?	0	50	0	50	0	50
Did you feel at ease using the toothbrush assigned to you?	49	1	48	2	48	2
Was the lodged food removed after brushing with the toothbrush allotted to you?	50	0	50	0	49	1
Did you manage to include the demonstration of the brushing technique that was provided to you?	50	0	50	0	50	0
Were you able to clean your back most teeth with the toothbrush provided to you?	48	2	46	4	47	3
Was the toothbrush allotted to you sustainable?	50	0	10	40	15	35
According to you, are bamboo toothbrushes economical to use?	50	0	45	5	46	4
Did you feel the need to use another dental aid for better cleaning experience along with the toothbrush?	24	26	26	24	30	20
Are bamboo toothbrushes currently available locally in your area?	45	5	5	45	4	46

Discussion

The toothbrush is both the most efficient and cost-effective method for mechanical plaque control. However, a significant drawback is that it has traditionally been made from plastic, which poses environmental hazards.¹⁰ In the 1990s, a range of new toothbrushes was introduced featuring various head designs, angles, shapes, sizes, and bristle types. These innovations made plaque removal more effective and efficient. Since then, manual toothbrushes have seen numerous design improvements, including changes to their handles, bristles, and head shapes and sizes. Today, toothbrushes come in a variety of designs, such as compact or standard sizes, and with bristles that can be soft, medium, or hard.¹¹

“Bogobrush” is a biodegradable toothbrush made from wood, typically referred to as a “bamboo toothbrush.” Unlike plastic toothbrushes, it can be disposed of in an ecofriendly manner, causing no harm to the environment. The main objective of these toothbrushes is to be environmentally sustainable. They are available in various forms, including foldable versions and those with plant seeds embedded in the handle, which, when buried, grow into a plant.¹² Duane et al. stated that the manufacturing of manual plastic toothbrushes results in approximately 2.5 million kg of CO₂ emissions annually. ^10,13,14

In this study, three types of toothbrushes were used: plastic, bamboo, and neem. The bamboo and neem toothbrushes were selected for their biocompatibility and increasing availability. Bamboo, a type of giant grass predominantly grown in China, is environmentally friendly. The study compared the effectiveness of these three toothbrushes in removing plaque. All participants were briefed about the study, and their parents signed a consent form. Before starting the trial, both parents and children received education on oral hygiene, and proper brushing techniques were demonstrated. Participants were given the same brand of toothpaste and instructed in the same brushing technique. Given the age range of 6–12 years, parents were also educated on the technique and asked to supervise their children to ensure consistency and avoid biases in the study.

The plaque score was assessed at the start of the study, after 1 month, and at the 3-month follow-up (Table 1). By the end of the 3 months, all three groups showed significant (p < 0.001) improvements in oral hygiene. However, the most noticeable improvement was observed in group B, followed by group A, and then group C. Pilcher et al. in Gujarat conducted a similar study and concluded that bamboo toothbrushes are considered a more sustainable alternative to plastic toothbrushes.¹⁴ Mistry concluded that a bamboo toothbrush can clean teeth as effectively as a plastic toothbrush.¹⁵

In this study, bamboo toothbrushes were found to be the most effective, followed by plastic toothbrushes, while neem toothbrushes were the least effective. The neem toothbrush in this study had slightly stiffer bristles compared to the plastic and bamboo toothbrushes. Rajeswaran et al. in their studies have observed that in terms of efficacy of plaque removal, the nylon brushes were most efficacious. Among the natural fiber brushes, bamboo and coconut demonstrated equal effectiveness, whereas ridge gourd was the least effective. Additionally, bamboo bristles showed superior resistance to wear compared to commercial nylon brushes.⁶

At the end of the study, patients' satisfaction with their assigned toothbrushes was also recorded through a questionnaire they were asked to complete (Table 2). In this study, participants did not notice bleeding during brushing in all the groups. Bhimani and Kothiwale reported that 85.96% of participants in the study did not experience any bleeding while brushing their teeth with the provided toothbrush.¹⁶

Participants were also inquired about the sustainability of their assigned toothbrushes. All participants in group A viewed their toothbrushes as sustainable, while 10 participants from group B and 15 participants from group C shared this view. Raidee et al. in Malaysia determined that identifying the key features of an ideal bamboo toothbrush could be an effective approach to minimizing the environmental impact of plastic in oral healthcare.¹⁷ Participants were also questioned about the effectiveness of their toothbrushes in removing food debris. All participants in groups A and B were satisfied with the results, while one participant from group C found that their toothbrush did not clean their teeth effectively. Venkatasubramani et al. concluded that bamboo toothbrushes with castor seed oil bristles had more cleaning efficacy when compared to other groups.¹⁷

Since bamboo and neem are organic materials, they may promote fungal and bacterial growth. In addition to assessing their plaque removal effectiveness, it is important to compare bacterial and fungal contamination between the bristle tufts of plastic and organic toothbrush heads. Avaneethram et al., in a study investigating the retention of Candida species on plastic vs bamboo toothbrushes, found that fungal growth was higher on bamboo toothbrushes compared to plastic, though the difference was statistically insignificant. Candida albicans was the most commonly found species on the toothbrush heads.¹⁸

The Centers for Disease Control and Prevention (CDC) recommends replacing a manual toothbrush every 3–4 months. Using it beyond this period can cause the bristles to become frayed and worn, reducing their effectiveness in removing plaque.

Natural toothbrushes are as effective as conventional ones in removing plaque, while also offering eco-friendly and biodegradable benefits. They serve as a sustainable alternative to plastic toothbrushes, combining effective oral hygiene with environmental responsibility.

Conclusion

Natural toothbrushes are equally effective as conventional toothbrushes for plaque removal and are eco-friendly and biodegradable. Natural toothbrushes can be used as an alternative to plastic toothbrushes. However, additional studies would be required to implement these results.

Clinical Significance

Identifying which type of toothbrush is most effective at removing plaque can guide recommendations for preventing dental caries and gum disease in children. Effective plaque control is crucial for reducing the incidence of these common dental problems.