Comparison of the Effectiveness of Three Different Types of Toothbrushes Among 8–12-year-old Children

Abstract

Background/objectives

Dental caries and periodontal diseases are considered the most common oral diseases that could be controlled by daily toothbrushing using a toothbrush. However, manual regular toothbrushing techniques may be performed incorrectly due to the inadequately developed motor skills of children. The new U-shaped toothbrush does not require as much control, and it is much easier to handle. Our objectives are to compare the effectiveness of plaque removal among three toothbrushes: Manual U-shaped toothbrush (U), battery-powered regular toothbrush (E), manual regular toothbrush (R), and the three above-mentioned to the control group (no brushing) (C).

Methods

This randomized controlled clinical trial was conducted at King Abdulaziz University Dental Hospital (KAUDH). A total of 56 participants (8–12-year-old) were randomly divided into the above-mentioned four groups. Two examiners conducted the study, where the first examiner was blinded to the type of toothbrush used, and was responsible for recording the full-mouth plaque score (FMPS) before and after brushing, while the second examiner was responsible for teaching children how to use the assigned toothbrush.

Results

For the FMPS means difference, a significant difference was found between the brushing groups (p < 0.001), post hoc testing showed statistically significant differences between (C) and (R) (p < 0.001), (C) and (E) (p < 0.001), (R) and (E) (p < 0.001), and (E) and (U) (p < 0.001), but not between (C) and (U) (p = 0.1229), or (R) and (U) (p = 0.1229).

Conclusion

The plaque removal efficiency was observed among (E), followed by (R), then (U) toothbrushes among children aged 8–12 years.

How to cite this article

Abdullah AM, Ainousa AM, Andijani BM, et al. Comparison of the Effectiveness of Three Different Types of Toothbrushes Among 8–12-year-old Children. Int J Clin Pediatr Dent 2025;18(11):1318–1321.

Introduction

Enhancing young children's oral health in a fair and efficient manner is a praiseworthy objective, and it is arguably achievable through the efforts of the dental profession. The microbial dental biofilm is the primary cause of dental caries and periodontal diseases, two of the most common oral disorders.^1,2 Epidemiological studies on the prevalence of dental caries among children in the Kingdom of Saudi Arabia showed that it is approximately 80% and 70% on the primary and permanent dentitions, respectively.³ In the presence of the untreated severely carious lesions, children's quality of life, general health, weight gain, and learning ability due to pain and discomfort are all negatively affected.^4–6 Poor oral hygiene practices and the accumulation of bacterial plaque are significant contributing factors to the development of gingivitis. Although destructive forms of periodontal disease are less prevalent in young individuals compared to adults, the buildup of dental plaque during childhood and adolescence can contribute to the development of periodontal disease later in life. Children with healthy gum tissues are more likely to maintain good periodontal health as they transition into adulthood.⁷ It is crucial to practice proper oral hygiene and reduce the buildup of bacterial dental biofilm on teeth to prevent these oral disorders.⁸ This can be achieved by maintaining proper dental hygiene, which primarily involves brushing teeth twice a day at home using a toothbrush and toothpaste that contains fluoride.⁹ However, due to children's limited motor abilities, regular manual toothbrushing may sometimes be performed incorrectly, as it relies on the patient's motor skills.¹⁰ The use of the new U-shaped toothbrush requires fewer motor skills and effort to ensure proper and thorough brushing. Moreover, children find it much simpler, easier, and more enjoyable to use.¹¹ Currently, we found that there are not enough studies conducted to test the efficacy of the manual U-shaped toothbrush when compared to the conventional powered toothbrush and manual habitual toothbrushes. Only one study was conducted by Nieri et al. on the adult population.⁸ In this study we want to investigate and compare the manual U-shaped toothbrush to the manual toothbrushes among the pediatric population where children at this age group establish their daily brushing habits on their own without much of parental supervision, by assessing the quality of plaque removal comparing three different brushing techniques by measuring full-mouth plaque score (FMPS) before brushing, after brushing and the FMPS difference among three different commercially available brushes in the market which are: The manual U-shaped toothbrush (U), the battery-powered regular toothbrush (E), and the manual regular toothbrush (R). All compared to the control group (C) with no brushing.

Materials and Methods

Ethical approval by the Research Ethics Committee at King Abdulaziz University, School of Dental Medicine (IRB#161-12-22) was obtained. This randomized controlled clinical trial (RCT) was conducted at King Abdulaziz University Dental Hospital (KAUDH) between March and April 2023, on a total of 56 participants, 8–12 years old, with no fixed orthodontic treatment, and a FMPS of 30% or above. Participants with disabilities, oral appliances, or silicone allergy were excluded.

The night before the visit, a text message reminder was sent to the participants to avoid all kinds of oral cleaning procedures, including chewing gum, approximately 12 hours before their appointment. After obtaining the consent form from the legal guardians, participants were randomly divided using 56 opaque and unnumbered envelops into four groups: 14 manual U-shaped toothbrushes (U) (Girls Boys 360 U-Shaped Toothbrush Children Soft Training Toothbrush Kids Manual Food Grade Piggy Cleaning Toothbrush 2–12 Year, China), 14 battery-powered regular toothbrush (E) (oral B, AA battery powered electric toothbrush for child age +3, China), 14 manual regular toothbrush (R) (Bamboo World Official, China), and the 14 control (no brushing group) (C). Patients' demographics were collected. The FMPS was measured using a disclosing solution; the participants were asked to swish for 30 seconds, then spit without rinsing. The first examiner, who was blinded to the randomly assigned toothbrush, counted the FMPS on six sites for each tooth, and the total number of teeth was also recorded. Then, the first examiner left the clinic, and the second examiner opened the sealed envelope the patient selected to know which intervention (type of toothbrush) the child was assigned to, then demonstrated the brushing technique for the child following the manufacturer's instructions for the selected toothbrush using the toothbrush and a model. Then, the child started brushing his/her own teeth for 2 minutes, under supervision, using the assigned toothbrush without toothpaste or water rinsing. Once done with the brushing, the child was given a disclosing solution and asked to swish for 30 seconds, then spit without rinsing. Then, the assigned toothbrush was hidden, and the first examiner entered the clinic to count the FMPS after brushing. Before dismissing the patient, one of the examiners cleaned the teeth to remove the pink stains using a toothbrush and toothpaste, and the assigned toothbrush was given as a gift.

Outcome Variable: FMPS

We recorded the presence or absence of plaque on six different sites per tooth (three buccal and three lingual), twice, before brushing and after brushing. Then we took the mean difference for the FMPS (FMPS = FMPS before brushing – FMPS after brushing). The FMPS was our main outcome variable was expressed as a percentage (the number of sites with plaque divided by the total number of examined sites) × 100.

Sample Size and Sampling Technique

When taking into consideration the mean difference of the FMPS 15, and a standard deviation of 12.90,¹² our sample size will be a total of 56 participants (14 per group), taking into account a significance level of α = 0.05 and a power of over 80%.

Statistical Analysis

We used mean and standard deviation for continuous variables and proportions and counts for categorical variables. The Kolmogorov–Smirnov test was conducted to test for normal distribution. We used the one-way analysis of variance (ANOVA) if the variable was normally distributed, and the Kruskal–Wallis test if not, to compare the mean FMPS for the four different groups of brushing techniques. Homoscedasticity was tested using the Bralette's test. For post hoc testing, we used the Bonferroni correction and the Mann–Whitney U-test between each pair (α = 0.008). A Chi-square test was conducted to compare the different brushing techniques among male and female participants. With the exception of the Bonferroni correction, the significance level was set at α = 0.05. All statistical analyses were performed on Stata/SE 15.1 (StataCorp, College Station, Texas, United States) statistical software.

Results

Descriptive Statistics

In this sample of population, 56 participants (14 per group), the means (±SD) for age were 9.96 (±1.28), where the youngest participant was 8 years old and the oldest was 12 years old. The mean total number of teeth was 22.28 (±1.92), with 17 teeth minimum and 26 teeth maximum. The FMPS means were as follows: Before brushing 62.22 (±14.38), after brushing 45.29 (±17.60), and for the mean difference for FMPS was 16.50 (±13.55). We had more female participants (N = 29, 51.79%) than male participants (N = 27, 48.21%), and with statistically nonsignificant differences between them for the different brushing techniques (p = 0.853 > 0.05) (Table 1).

Table 1:

Descriptive summary of populations' gender, age, and oral findings

Variable	Number (N)		Percentage (%)		p-value
Male	27		48.21		0.853*
Female	29		51.79
Variable	Mean	SD	Median	Min	Max
Age	9.96	1.28	10.00	8.00	12.00
Total number of teeth	22.38	1.92	23.00	17.00	26.00
FMPS before brushing	62.22	14.38	62.41	31.25	95.83
FMPS after brushing	45.29	17.60	46.82	11.80	79.86
FMPS difference	16.50	13.55	13.89	0.79	45.45

SD, Standard deviation, ^*Chi-square test was conducted showing no statistically significant difference between male and female participants when using different types of toothbrushes (p = 0.853)

Comparison Between Different Tooth Brushing Techniques (FMPS after Brushing)

The FMPS after brushing indicates the amount of plaque accumulation left after brushing. The mean (±SD) was higher for control 58.21 (±15.39), U-shaped 55.53 (±9.47), and regular 41.13 (±14.09), when compared to electric toothbrush 26.32 (±9.34). The comparison of brushing techniques using one-way ANOVA was statistically significant (p < 0.001). In post hoc testing there was a statistically significant difference between control and regular (p = 0.007), between control and electric (p < 0.001), and between electric and U-shaped (p < 0.001) but not between control and U-shaped (p = 1), and not between regular and electric (p = 0.012) or between regular and U-shaped (p = 0.02) (Table 2).

Table 2:

Mean and standard deviation for FMPS before and after brushing, and FMPS difference for each brushing technique

Outcome variables	Brushing techniques								p-value
	Control (C)		Regular (R)		Electric (E)		U-shaped (U)
	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Age	9.79	1.53	10.07	1.07	9.43	1.02	10.57	1.28	0.130
FMPS before brushing	62.82	14.70	65.27	19.39	57.28	12.29	63.51	9.64
FMPS after brushing	58.21	15.39	41.13	14.09	26.32	9.34	55.53	9.47	<0.001*
FMPS difference	4.61	2.58	24.15	11.64	30.96	9.89	7.98	5.23	<0.001**

^*For the FMPS after brushing: A one-way ANOVA was conducted to compare means of different brushing techniques at p < 0.05; the result was statistically significant (p < 0.001). In the post hoc analyses (p < 0.008), a statistically significant difference was found between (C) and (R) (p = 0.007), between (C) and (E) (p < 0.001), and between (E) and (U) (p < 0.001) but not between (C) and (U) (p = 1), between (R) and (U) (p = 0.02), and not between (R) and (E) (p = 0.012); ^**For the FMPS difference: A Kruskal–Wallis test was conducted to compare means of different brushing techniques at p < 0.05; the result was statistically significant (p < 0.001). Post hoc analyses (p < 0.008), a statistically significant differences were found between (C) and (R) (p < 0.001), between (C) and (E) (p < 0.001), between (R) and (U) (p = 0.001), and between (E) and (U) (p < 0.001), but not between (C) and (U) (p = 0.0962) and not between (R) and (E) (p = 0.085)

Comparison Between Different Tooth Brushing Techniques (FMPS Difference)

For the FMPS difference, the mean (±SD) was higher for the electric tooth brush 30.96 (±9.89), an example for before and after brushing is shown in Figure 1, regular, 24.15 (±11.64), U-shaped 7.98 (±5.23), when compared to the control 4.61 (±2.58). The higher the FMPS difference, the better the tooth brushing technique. The comparison of brushing techniques using the Kruskal–Wallis test was statistically significant (p < 0.001). In post hoc testing there was a statistically significant difference between the following: Control and regular (24.15 – 4.61 = 19.54) (p < 0.001) favoring the regular, between control and electric (30.96 – 4.61 = 26.35) favoring electric (p < 0.001), between electric and U-shaped (30.96 – 7.98 = 22.98) favoring electric (p < 0.001), and between regular and electric (30.96 – 24.15 = 6.81) favoring the electric (p < 0.001), but not between control and U-shaped (7.98 – 4.61 = 3.37) favoring U-shaped (p = 0.1229), nor between regular and U-shaped (24.15 – 7.98 = 16.17) favoring regular (p = 0.1229) (Table 2).

Figs 1A and B:

Intraoral pictures showing the FMPS after applying the disclosing solution: (A) Before brushing; (B) After brushing

Discussion

Dental caries and periodontal disease are common among the pediatric population due to the microbial dental biofilm^1,2; to reduce the negative effect of dental biofilm and to prevent the occurrence of these diseases, the child must maintain good oral hygiene conditions. Maintaining good oral hygiene can be achieved by the utilization of a toothbrush coupled with a toothpaste; a wide variety of toothbrushes can be found in the market. Incorrect toothbrushing techniques can be observed among children due to inadequate motor skills.^9,11 The U-shaped toothbrush was developed with a different design than the conventional toothbrush; it does not require adequate fine motor skills to perform toothbrushing adequately. The U-shaped toothbrush has very simple and easy instructions for the child to understand and perform them. Not enough studies were conducted to evaluate the effectiveness of plaque removal using the manual U-shaped toothbrush.

This RCT was conducted to assess the effectiveness of plaque removal of a manual U-shaped toothbrush, a battery-powered regular toothbrush, a manual regular toothbrush, and no brushing in children aged 8–12 years. Results obtained from this study rejected our alternative hypothesis regarding the manual U-shaped toothbrush being the most effective toothbrush for plaque removal in children between 8 and 12 years. To the best of our knowledge, this clinical trial is the first one to assess the plaque removal effectiveness of the manual U-shaped toothbrush among Saudi children. This study reported that there were no statistically significant differences regarding FMPS before brushing among different groups at the baseline. Additionally, regarding the effectiveness of plaque removal, both battery-powered regular toothbrush and manual regular toothbrush were more effective when compared to manual U-shaped toothbrush and no brushing groups, our findings are similar to what was reported by Nieri et al.,⁸ despite the difference in the study population type (children vs dental students). Manual regular toothbrushes are considered the cheapest and most affordable toothbrushes in the market, easy to reach and available everywhere. On the other hand, manual toothbrushes need adequate motor skills and technique, which makes it difficult for children to use them.¹⁰ In this study, we found that both battery-powered regular toothbrush and manual regular toothbrush were the most effective brushing techniques for plaque removal when compared to the other brushing techniques: The manual U-shaped toothbrush and the no brushing group. The battery-powered regular toothbrush was superior to the manual regular toothbrush in plaque removal. Our results were consistent with the literature, where in a recent meta-analysis study by Yaacob et al.,¹³ the battery-powered regular toothbrushes showed superior results when compared to manual regular toothbrushes with regard to oral hygiene and dental plaque reduction.¹³ Furthermore, a recent RCT showed effective plaque removal in the premolar and molar areas (p < 0.05) after using a battery-powered regular toothbrush; however, in the central incisor area, there was no significant difference between manual regular and battery-powered regular toothbrushes in plaque removal.¹⁴ Findings from our study reported that utilization of manual U-shaped toothbrush were worse when compared to manual regular toothbrush and battery-powered regular toothbrush, similar findings were reported by a study conducted by Nieri et al.,⁸ a possible explanation could be due to the poor fit of the manual U-shaped toothbrush silicon bristles to teeth surface, the silicon bristles lack the proper hardness that facilitate adequate plaque removal, as well as the possibility of not reaching the gingival third of tooth surface, manual U-shaped toothbrush come in fixed size, and shape which might not fit properly on the dental arch. Additionally, another study showed the manual U-shaped electrical toothbrush had a high percentage of plaque remaining on the typodont, and they used image processing using ImageJ software.¹⁵ Limitations of this study include the lack of long-term follow-up; our study only assessed the dental plaque score with no regard to the clinical presentation of the gingival condition. participants were recruited from a single institution, coupled with the limited age range of our participants (8–12-year-old), these factors limit the generalizability of our results. More clinical research should be done to assess the long-term effects of the manual U-shaped toothbrush and its effectiveness among children older than 12 years. Another limitation in our study is that we did not assess the child's compliance, child's satisfaction, or parental satisfaction; future studies are needed to assess these factors. Another recommendation is to assess the effectiveness U-shaped toothbrush in plaque removal among children with physical and intellectual disabilities, as people with intellectual disabilities have the tendency to have a greater chance of having periodontal diseases, as reported by Waldron et al.¹⁶

Conclusions

The manual U-shaped toothbrush reduces plaque less than both the battery-powered regular toothbrush and the manual regular toothbrush in the short-term follow-up. Study findings suggest that a manual U-shaped toothbrush cannot replace the manual regular or battery-powered regular toothbrush for regular oral hygiene practice in children aged 8–12 years.

Orcid

Abeer M Abdullah https://orcid.org/0000-0003-4228-7145

Basil M Andijani https://orcid.org/0009-0003-6077-9386

Faisal M Dardeer https://orcid.org/0000-0003-2739-2502

Mohammed Alulaiyan https://orcid.org/0000-0002-8908-4110

Shahad N Abudawood https://orcid.org/0009-0005-6589-3430