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. 2026 Mar 9;26:678. doi: 10.1186/s12903-026-08046-7

Evaluation of plaque removal by triple-headed manual toothbrush: a randomized controlled clinical trial

Merve İşcan Yapar 1, Didem Özkal Emi̇noğlu 2,✉, Didar Betül Doğan 2, Güler Başyi̇ği̇t 2, Kamber Kaşali̇ 3
PMCID: PMC13085586  PMID: 41803789

Abstract

Objectives

This examiner-blinded, randomized controlled trial compared the plaque removal efficacy of a triple-headed manual toothbrush (3HB) to a conventional manual toothbrush.

Materials and methods

Forty-eight non-smoker, right-handed participants (aged 20–50 years) were randomly grouped: The first group (Conventional Manual Toothbrush-CMB) was given a manual toothbrush and the second group (3Head Brush-3HB) was given a toothbrush with a 3-head geometric design. All participants were assessed with The Rustogi et al. Modified Navy Plaque Index (RMNPI). Clinical trial registration number of the present study is “NCT06594757”.

Results

Forty-eight eligible participants were randomized into two groups (n = 24 each). No significant differences in baseline demographics were observed. Plaque scores evaluated before and after brushing showed no significant difference between the groups in marginal, aproximal, anterior, premolar and whole mouth regions. However, there was a statistically significant decrease in plaque scores in all regions after brushing in both groups (p < 0.001). There was also no significant difference between genders in terms of plaque scores, while plaque reduction was effective regardless of age or gender in all regions after brushing (p < 0.001). The findings suggest that both toothbrush designs are effective in plaque removal.

Conclusions

The triple-headed manual toothbrush demonstrated plaque removal efficacy statistically comparable to, but not superior to, the conventional manual toothbrush in healthy, non-impaired adults. Its clinical advantage may be specific to populations with manual dexterity challenges.

Clinical relevance

Problems related to teeth and gums can be prevented and controlled by appropriate mechanical cleaning of dental plaque. In order to successfully remove microbial dental plaque, teeth should be brushed regularly, for sufficient time and with the correct technique. Toothbrush manufacturers continue to work to remove plaque better with different designs of the head of the toothbrush. It is tried to increase the plaque removal efficiency of classical brushes with different designs of areas such as bristles, handle, head angle and structure. The effectiveness of different toothbrush designs has been demonstrated in studies investigating plaque removal efficiency, especially in interproximal and gingival areas that can be cleaned more difficult. This study’s results demonstrated that removing plaque from the tooth surface by effective tooth brushing may help improve oral health.

Trial registration

ClinicalTrials.gov Identifier: NCT06594757, registered on September 09, 2024 (retrospectively registered).

Keywords: Microbial dental plaque, Modified Bass Technique, Oral hygiene, Rustogi Modifiye Navy Plaque Index, Toothbrush

Introduction

The human body hosts diverse microbiomes, including bacteria, viruses, and fungi [1]. Among oral diseases, dental caries and periodontal disease are highly prevalent worldwide and remain leading causes of tooth loss, with major impacts on oral health [2]. Caries are biofilm-induced lesions driven by sugar-dependent microbial growth and carbohydrate metabolism, which disrupt tooth mineralization and lead to localized acidification [3]. Periodontitis, in contrast, is a chronic inflammatory condition triggered by plaque biofilm and mediated by host immune responses [4].

Dental biofilms, composed of bacterial colonies, fungi, algae, and debris, are central to the development of caries, periodontitis, and peri-implantitis [5–7]. Their pathogenic impact arises from the dynamic interaction between the oral microbiome, host factors, and diet or immunity depending on the disease context [8, 9]. Importantly, research demonstrates that consistent mechanical removal of plaque through regular toothbrushing and interdental cleaning effectively prevents these biofilm-related conditions [10].

The natural cleansing mechanisms of the oral cavity may be capable of removing food debris, but they are not highly efficient at removal supragingival plaque [11]. Brushing has been recognized as the main and efficient technique for eliminating plaque and soft debris. Aside from toothbrushing, effective management of the plaque biofilm may include the use of complementary approaches like as mechanical flossing and chemotherapeutic mouthrinses [12].

Various brushing equipment and instruments have been designed to effectively remove plaque, including as manual toothbrushes and electric toothbrushes with different types of movements. Despite the notable rise in sales of electronic toothbrushes in recent years and the evidence from studies indicating that powered toothbrushes are more effective than manual toothbrushing in reducing plaque and gingivitis over both the short and long term [13], the majority of consumers still favor using manual toothbrushes [14]. Manual or powered tooth brushing may not be effectively executed in some circumstances, such as with disabled adults and children [15, 16]. Consequently, there is a continuous quest for alternate approaches and materials to enhance the efficiency of mechanical plaque removal such as smartphone applications [17], musical toothbrush [18], chewable toothbrush [19], another option among these choices is triple-headed toothbrush [20]. The triple-headed toothbrush is designed tobased on the idea of brushing several sites of the tooth at one time. This toothbrush is intended to reach the gingival tooth margin, and to clean the buccal, occlusal, and lingual surfaces of the teeth simultaneously [21]. While the triple-headed brush shows promise for populations with limited dexterity, its fundamental plaque-removal efficacy relative to theconventional gold standard in a general adult population requires rigorous evaluation to establish its baseline utility. This study aims to compare the plaque removal effectiveness of the conventional manual toothbrush versus triple-headed manual toothbrush by chairside clinical plaque scoring.

The null hypothesis (H₀) was that there would be no difference in plaque removal efficacy between the two toothbrush designs. The alternative hypothesis (Hₐ) was that the triple-headed toothbrush would lead to a statistically significant reduction in plaque index compared to the conventional manual toothbrush.

Materials and methods

Study design, registration, ethical approvals

This clinical trial was designed as a randomized, controlled, examiner-blinded study with two parallel arms. Before the study, each participant was informed individually about all study protocol and all participants signed a written consent form in accordance with the Helsinki Declaration of 1975 (2013 revision). The study was designed and reported in compliance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The ethical approval was obtained from “The Ethics Committee Of The Faculty Of Dentistry at Ataturk University” (meeting date: 29.12.2022; meeting number: 12, decision no:97). The study was retrospectively registered at ClinicalTrials.gov (NCT06594757) due to administrative delays. No protocol changes were made after study initiation and that all outcomes were predefined prior to participant enrollment.

The study was conducted at the Atatürk University, Faculty of Dentistry, Department of Periodontology Clinic, Erzurum, Türkiye, between 1 January 2024 and 1 December 2024.

Sample size

G-Power® version 3.1 (University of Düsseldorf, Düsseldorf, Germany) was used for sample size estimation. With reference to the article titled “Correlations Between Two Plaque Indices in Assessment of Toothbrush Effectiveness”, the score of the RMNPI, which is used to compare the plaque removal efficiency of the conventional manual toothbrush and the toothbrush with 3-headed geometric design, is 0. 27 ± 0.03 and 0.245 ± 0.03, respectively, it was calculated that for the difference of 0.025 (effect size d = 0.83) to be significant, 24 individuals in each group and 48 individuals in total should be included in the study with 80% power and 95% confidence level.

Study population and intervention

The subjects were recruited among patients attending periodontal health care. The inclusion criteria were: age between 18 and 60 years, 24 teeth minimum (6*4), no systemic or periodontal problems, right-handedness in tooth brushing, absence of class V filling and non-carious cervical lesions, no orthodontic treatment, and presence of plaque on the tooth surface after staining solution application.

The study excluded participants with systemic diseases or conditions, neurological or psychiatric disorders, physical or mental disabilities, smoking habits, or medication use (e.g., phenytoin, cyclosporine, calcium channel blockers such as nifedipine) that could impact periodontal health [22, 23]. Individuals with a history of periodontal disease treatment or recent usage of antibacterial mouth rinses in the preceding six months were also excluded.

The subjects abstained from oral hygiene practices (toothbrushes, dental floss, interdental brushes, and/or mouthwash) for 48 h before each recording so as to promote accumulation of dental plaque [24]. Dental plaque was discolored with a plaque revealing solution, after which individuals were instructed to rinse their mouths thoroughly four times with water. Plaque was disclosed using a pre-soaked sponge pellet (EMS) [25]. The amount of plaque was scored using the RMNPI [26, 27] (Fig. 1).

Fig. 1.

Fig. 1

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The rustogi modification of the navy plaque index [28]

Participants were divided into two groups: Group 1 (CMB) (n = 24): Brushing with the conventional single-headed (control) manual toothbrush (738 Paro® M27L, Switzerland) (Fig. 2); Group 2 (3HB) (n = 24): Brushing with the triple-headed manual toothbrush (724 Paro® SuperBrush, Switzerland) (Fig. 3). The tooth cleaning technique (Modified Bass Technique) [29] was demonstrated for each participant individually and face to face, and participants in the CMB group were instructed to perform brushing using this technique during the study session. All participants in the 3HB group were instructed to place the brush heads simultaneously on the buccal, occlusal, and lingual surfaces and perform a gentle scrubbing motion, ensuring all surfaces were covered.

Fig. 2.

Fig. 2

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Conventional single-headed manual toothbrush (738 Paro® M27L, Switzerland)

Fig. 3.

Fig. 3

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Triple-headed manual toothbrush (724 Paro® SuperBrush, Switzerland)

The patients were requested to brush their teeth after the demonstration of brushing procedures. Toothpaste has not been used in all subjects to observe the pure brushing effect and to ensure standardization [30]. All participants were recommended to brush for two minutes [31]. Following toothbrushing scoring of remaining plaque was performed. The procedure lasted approximately 20 min and was performed in a quiet environment [32].

Randomization and blinding

Participants were divided into two groups using the https://www.randomizer.org/ website. A research randomizer is a tool that generates random numbers to allocate people for clinical trials. This software can be classified as a “pseudo-random number generator,” like many other computer-based generators. It utilizes a sophisticated algorithm initialized by the computer’s clock to produce random numbers [33]. The first practitioner evaluated the patients for eligibility. The second practitioner applied a disclosing agent to the dental plaque and recorded plaque scores before and after toothbrushing. The third practitioner demonstrated the toothbrushing techniques to the patients. To preserve blinding, the examiner (second practitioner) was not present in the room during the brushing procedure, and participants were instructed not to discuss the type of toothbrush they were using. Statistical analyzer was blinded to the groups of the patients.

Statistical analysis

Statistical analyses were conducted using IBM SPSS Statistics version 20. Data were presented as mean, standard deviation, median, minimum, maximum, percentage, and frequency. The normality of continuous variables was evaluated using the Shapiro-Wilk test, Kolmogorov-Smirnov test, Q-Q plots, skewness, and kurtosis. For comparisons between two independent groups, the Independent Samples t-test was used when the assumption of normality was met; otherwise, the Mann-Whitney U test was applied. For comparisons between two related groups, the Paired Samples t-test was used when the data followed a normal distribution, while the Wilcoxon signed-rank test was employed when normality was not observed. The chi-square test was used to compare proportions between two groups. A p-value of < 0.05 was considered statistically significant.

Results

A total of 257 individuals were assessed for eligibility. Of these, 209 were excluded (120 declined participation, 89 did not meet the inclusion criteria). Forty-eight participants were enrolled and randomly assigned to two groups (n = 24 each) (Fig. 4).

Fig. 4.

Fig. 4

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CONSORT flow diagram

In the CMB group, there were 13 male and 11 female participants (mean age: 30 years), while the 3HB group included 12 male and 12 female participants (mean age: 30 years). The demographic characteristics by age and sex are presented in Tables 1 and 2, showing no statistically significant differences between groups.

Table 1.

Demographic characteristics of participants

GROUP
CMB 3HB
Count Column N % Count Column N % Chi-square test p
GENDER M 13 54,20% 12 50,00% 0,083 0,773
F 11 45,80% 12 50,00%
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M Male, F Female, CMB Conventional Manual Toothbrush, 3HB 3-headed brush

Table 2.

Comparison of age information of female and male participants between groups

GROUP
CMB 3HB
Mean StandardDeviation Median Minimum Maximum Mean Standard Deviation Median Minimum Maximum Z p
AGE 30 8 27 21 47 30 7 29 20 50 -0,578 0,563
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CMB Conventional Manual Toothbrush, 3HB 3-headed brush, Z Mann Whitney u test

As detailed in Tables 3 and 4, no statistically significant differences in plaque scores were observed between the CMB and 3HB groups at any site, either before or after brushing. However, both groups demonstrated a highly significant reduction in plaque scores across all tooth regions after brushing (p < 0.001).

Table 3.

Comparison of marginal, aproximal and whole mouth score before and after between groups

GROUP
CMB 3HB
Mean Standard Deviation Median Minimum Maximum Mean Standard Deviation Median Minimum Maximum t, Z1 pa
MARGİNAL BEFORE (A+B+C) 0,76 0,22 0,84 0,32 1,00 0,71 0,25 0,79 0,21 1,00 -0,619 0,536
MARJİNAL AFTER (A+B+C) 0,21 0,18 0,18 0,01 0,79 0,21 0,23 0,13 0,00 0,95 -0,608 0,543
Z2 -4,286 -4,057
pb <0.001 <0.001
APROXİMAL BEFORE (D+F) 0,24 0,22 0,19 0,00 0,83 0,28 0,27 0,22 0,00 0,96 -0,340 0,734
APROXİMAL AFTER (D+F) 0,03 0,06 0,01 0,00 0,20 0,02 0,06 0,00 0,00 0,23 -0,808 0,419
Z2 -4,015 -4,198
pb <0.001 <0.001
WHOLE SCORE  BEFORE 0,33 0,14 0,34 0,14 0,58 0,34 0,18 0,34 0,09 0,79 0,089 0,930
WHOLE SCORE  AFTER 0,08 0,07 0,07 0,00 0,30 0,07 0,07 0,03 0,00 0,29 -1,021 0,307
Z2 -4,286 -4,286
pb <0.001 <0.001
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CMB Conventional Manual Toothbrush, 3HB 3-headed brush, t Independent samples t test, Z1 Mann whitney u test, Z2 Wilcoxon test

pa<0.05: indicates a statistically significant intragroup difference, pb<0.05: indicates a significant difference between groups

Table 4.

Comparison of anterior, premolar, posterior scores before and after between groups

GROUP
CMB 3HB
Mean Standard Deviation Median Minimum Maximum Mean Standard Deviation Median Minimum Maximum t, Z1 pa
WHOLE SCORE  BEFORE 0,33 0,14 0,34 0,14 0,58 0,34 0,18 0,34 0,09 0,79 0,089 0,930
WHOLE SCORE  AFTER 0,08 0,07 0,07 0,00 0,30 0,07 0,07 0,03 0,00 0,29 -1,021 0,307
Z2 -4,286 -4,286
pb <0.001 <0.001
ANTERIOR BEFORE 0,33 0,18 0,32 0,06 0,84 0,33 0,20 0,33 0,00 0,83 -0,048 0,962
ANTERIOR AFTER 0,10 0,13 0,05 0,00 0,39 0,05 0,08 0,02 0,00 0,36 -0,862 0,389
Z2 -4,198 -4,198
pb <0.001 <0.001
PREMOLAR BEFORE 0,32 0,14 0,33 0,05 0,58 0,29 0,19 0,27 0,03 0,74 0,387 0,701
PREMOLAR AFTER 0,06 0,08 0,03 0,00 0,30 0,05 0,07 0,01 0,00 0,25 -1,010 0,313
Z2 -4,288 -4,287
pb <0.001 <0.001
POSTERIOR BEFORE 0,44 0,22 0,40 0,02 0,88 0,40 0,19 0,38 0,14 0,79 0,042 0,966
POSTERIOR AFTER 0,15 0,13 0,15 0,00 0,57 0,11 0,10 0,08 0,00 0,41 -1,559 0,119
Z2 -4,258 -4,287
pb <0.001 <0.001
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CMB Conventional Manual Toothbrush, 3HB 3-headed brush, t Independent samples t test, Z1 Mann whitney u test, Z2 Wilcoxon test

pa<0.05: indicates a statistically significant intragroup difference, pb<0.05: indicates a significant difference between groups

Similarly, gender-based comparisons (Table 5) revealed no significant differences in plaque reduction between male and female participants (p > 0.05), although both genders exhibited a significant decrease in plaque levels following brushing (p < 0.001).

Table 5.

Comparison of plaque scores between genders

GENDERS
MALE FEMALE
Mean Standard Deviation Median Minimum Maximum Mean Standard Deviation Median Minimum Maximum t, Z1 p a
MARGINAL BEFORE (A + B+C) 0,79 0,20 0,83 0,29 1,00 0,68 0,27 0,65 0,21 1,00 -1,249 0,212
MARGINAL AFTER (A + B+C) 0,21 0,20 0,17 0,00 0,79 0,20 0,21 0,15 0,00 0,95 -0,361 0,718
Z2 -4,373 -3,924
pb < 0.001 < 0.001
APROXIMAL BEFORE (D + F) 0,23 0,20 0,20 0,00 0,83 0,29 0,28 0,19 0,00 0,96 -0,444 0,657
APROXIMAL AFTER (D + F) 0,03 0,06 0,02 0,00 0,20 0,02 0,05 0,00 0,00 0,23 -0,957 0,339
Z2 -4,198 -4,015
pb < 0.001 < 0.001
WHOLE SCORE BEFORE 0,34 0,11 0,34 0,10 0,55 0,33 0,19 0,26 0,09 0,79 0,090 0,928
WHOLE SCORE AFTER 0,08 0,08 0,07 0,00 0,30 0,06 0,05 0,05 0,00 0,22 -0,568 0,570
Z2 -4,372 -4,197
pb < 0.001 < 0.001
ANTERIOR BEFORE 0,33 0,16 0,33 0,06 0,63 0,33 0,23 0,33 0,00 0,84 -0,048 0,962
ANTERIOR AFTER 0,08 0,12 0,03 0,00 0,39 0,07 0,09 0,04 0,00 0,39 -0,431 0,666
Z2 -4,287 -4,108
pb < 0.001 < 0.001
PREMOLAR BEFORE 0,32 0,12 0,33 0,09 0,57 0,30 0,20 0,25 0,03 0,74 0,387 0,701
PREMOLAR AFTER 0,07 0,09 0,03 0,00 0,30 0,04 0,05 0,03 0,00 0,18 -0,737 0,461
Z2 -4,375 -4,198
pb < 0.001 < 0.001
POSTERIOR BEFORE 0,42 0,19 0,39 0,16 0,88 0,42 0,22 0,39 0,02 0,79 -0,072 0,942
POSTERIOR AFTER 0,15 0,13 0,14 0,00 0,57 0,11 0,10 0,08 0,00 0,41 -1,096 0,273
Z2 -4,373 -4,167
pb < 0.001 < 0.001
Open in a new tab

t Independent samples t test, Z1 Mann Whitney u test, Z2 Wilcoxon test

pa<0.05: indicates a statistically significant intragroup difference, pb<0.05: indicates a significant difference between groups

Discussion

The principal finding of the present study is that the triple-headed manual toothbrush was not superior to the conventional manual toothbrush in removing dental plaque in a cohort of healthy adult population with no physical or orthodontic limitations.

In this study, there was no significant difference in plaque removal between different brush designs, CMB and 3HB, when different tooth sites (anteior, posterior, whole) and different tooth surfaces (marginal, aproximal, total tooth surface) were compared. Our findings are in agreement with those of [34], who also reported equivalent efficacy between the two brush types in a self-performed oral hygiene setting. This study involved 21 participants evaluated the amount of dental plaque before and after brushing with a three-headed and single-headed manual toothbrush after 48 h of plaque accumulation. In a study performed by Vanstraelen, Tarce, de Almeida Mello, et al., the plaque removal effectiveness and brushing times of conventional and three-headed manual toothbrushes were evaluated. In the study, which included 21 participants, although brushing time was reduced with the three-headed manual toothbrush compared to the conventional toothbrush, plaque removal effectiveness was found to be similar in both toothbrushes. Different from our study, the brushing time was the same in both groups. Plaque removal efficacy was evaluated independently of brushing time. Similar to other studies, conventional and three-headed manual toothbrushes were found to have similar efficacy in plaque removal. In a study reported in the literature, the plaque removal efficacy of a three-headed manual toothbrush was evaluated in comparison with a conventional manual toothbrush and a rotary-headed brush, with each group consisting of 12 patients. The results demonstrated that the three-headed manual toothbrush was significantly more effective in removing dental plaque than the other toothbrush types [35]. In our current study, participants in the 3HB group received detailed training on the correct positioning and application of the brush using a plastic model, while participants in the CMB group were shown the Modified Bass Technique using a plastic model. In both groups without any limitations in motor skills, a decrease in plaque scores was observed after brushing, and no significant difference was found between the plaque scores of the two groups. In addition to the potential advantages of the three-headed brush, it was observed that the Modified Bass Technique brushing method achieved similar plaque removal efficacy compared to the single-headed brush, when combined with effective oral hygiene education and proper technique guidance. One possible explanation for the lack of difference is that the Modified Bass technique, when properly performed, may be highly efficient in disrupting and removing dental plaque, thereby masking any potential mechanical advantage offered by the three-headed brush design. Alternatively, the 3HB may require a different or simplified brushing motion to fully realize its design benefits, which might not have been fully reflected under the standardized brushing conditions of this study.

In the literature evaluating oral hygiene habits and oral health scores, it has been observed that women are more inclined to practice oral hygiene habits than men, and therefore their oral health scores are better than those of men [36]. According to Abe et al. [37], male participants demonstrated significantly poorer oral hygiene behaviors compared to females, brushing less frequently and for shorter durations, which was associated with higher plaque accumulation and gingival inflammation [37]. Although it has been suggested that there may be gender differences in oral hygiene habits, it has been reported that when proper oral hygiene education and guidance are provided, gender differences in plaque removal effectiveness can be significantly reduced [38]. Our current study found a significant decrease in plaque scores in both genders compared to before brushing; however, no significant difference was observed between female and male participants in plaque removal. The result that there is no difference in plaque scores between genders after effective brushing with proper guidance supports the literature.

In the literature, several studies have investigated the effectiveness of three-headed manual toothbrushes in patients undergoing orthodontic treatment, a population in which plaque removal is often more challenging. In one study, 37 male and 57 female orthodontic patients were randomly assigned to three groups to evaluate the plaque removal efficacy of conventional, orthodontic, and three-headed manual toothbrushes. The findings demonstrated that, in terms of improving gingival health and bracket cleaning, the three-headed manual toothbrush was more effective than the other toothbrushes when compared to pre-brushing values [39]. Similarly, another study compared the plaque removal ability of a three-headed manual toothbrush with that of a traditional single-headed manual toothbrush in 60 patients undergoing fixed orthodontic treatment. Participants were randomly divided into two equal groups, and the results showed that the three-headed toothbrush achieved significantly greater reductions in plaque indices compared to the traditional manual toothbrush. These findings suggest that the use of a three-headed manual toothbrush provides superior plaque control in patients with fixed orthodontic appliances [40].

The potential advantages of three-headed toothbrushes include their ability to simultaneously contact multiple tooth surfaces and their better adaptation to the cervical region of the tooth. Previous studies have suggested that this design may facilitate ease of use for specific patient groups, such as individuals with limited motor skills [41]. For example, in a study involving 28 male and 15 female patients with cerebral palsy, oral hygiene care was provided by nurses using either a single-headed manual toothbrush (21 participants) or a three-headed manual toothbrush (22 participants). The findings indicated that the three-headed toothbrush was more effective in maintaining oral hygiene compared to the single-headed toothbrush in this patient population [42]. Similarly, a systematic review comparing the plaque removal efficacy of three-headed versus single-headed manual toothbrushes reported that the three-headed brush demonstrated superior effectiveness, particularly among individuals whose oral care was performed by caregivers [41]. Furthermore, in a study evaluating the plaque removal effectiveness of three different toothbrush types in children with mild intellectual disabilities, including a manual three-headed brush, a novel manual toothbrush, and an electric toothbrush with a rotary-oscillating head, 30 patients were assessed across two age groups (6–12 years and 13–18 years). The electric toothbrush demonstrated the highest plaque removal efficacy, while the three-headed manual toothbrush was considered a suitable alternative for plaque control in children with mental disabilities [43].

The apparent superiority of the triple-headed brush reported in several studies (39, 40, 42, 43, 44) appears to be context-dependent. These studies involved populations with specific challenges, such as orthodontic appliances, cognitive disabilities, or reliance on caregivers. In these situations, the design of the triple-headed brush may compensate for difficulties in technique or dexterity. This highlights that the effectiveness of a toothbrush design cannot be evaluated in isolation but should be interpreted in the context of the user’s abilities and oral conditions. The 3HB’s main advantage may therefore lie in its ability to facilitate plaque removal in individuals with limited manual dexterity or anatomical constraints, such as those with braces or requiring caregiver-assisted brushing, rather than in inherently superior plaque-removing capability. Our study, which excluded such factors, demonstrates that when used by motivated adults without physical limitations, both brush designs, when accompanied by proper instruction, are equally effective.

Limitations

This study has several limitations that should be acknowledged. The study population consisted of motivated adult participants without physical or cognitive impairments; therefore, the findings cannot be generalized to pediatric or disabled populations, in whom manual dexterity and brushing assistance requirements differ. Toothbrushing was performed without toothpaste to isolate the mechanical effect of brushing and eliminate potential confounding factors; however, this does not fully reflect real-world oral hygiene practices where toothpaste is routinely used, and thus the generalizability of our findings to daily conditions should be interpreted with caution. In addition, the trial primarily assessed the short-term effect of a single brushing session, without evaluating long-term outcomes such as gingival health. Participants were aware of being observed, which may have led to improved performance due to the Hawthorne effect. Furthermore, participants were not their own controls, and a crossover design might have provided greater statistical power. Finally, the evaluation was restricted to immediate post-brushing plaque removal and did not capture sustained effects over time.

Future studies should address the microbial ecology underlying dental caries, which was not investigated in the present trial. The caries-associated microbiome is diverse, dynamic, and site-specific [44, 45], and population-based research has shown identifiable distribution patterns across dentition with symmetrical involvement and inter-tooth correlations [46, 47]. Longitudinal trials integrating microbial profiling and caries pattern analysis may clarify how toothbrush design and oral hygiene practices influence not only plaque removal but also the ecological balance of cariogenic biofilms [48, 49].

Conclusion

Within the limitations of this study, the triple-headed manual toothbrush was found to be as effective as a conventional manual toothbrush for plaque removal in motivated, healthy adults with normal manual dexterity. Therefore, while its use does not provide a significant advantage in the general population, its primary clinical indication may be for individuals who experience difficulty in performing proper brushing techniques, such as those with orthodontic appliances, physical or cognitive disabilities, or those relying on caregiver-assisted oral hygiene.

Authors’ contributions

DÖE have made substantial contributions to conception, design, writing orginal draft of the study; MİY contritubed to conceptualization, validation of the study; DBD contributed to research, editing, writing orginal draft of the study; GB have been involved in data collection, design; KK have been involved in data analysis, data interpretation, drafting the manuscript; All authors have been involved in revising and have given final approval of the version to be published; All authors agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

This study was funded by the “Scientific Research Projects Coordınatıon Unit of Atatürk University (TSA-2023-13318).”

Data availability

Özkal Eminoğlu, D. (2025). Evaluation of Plaque Removal by Triple-Headed Manual Toothbrush: A Randomized Controlled Clinical Trial [Data set]. Zenodo. 10.5281/zenodo.14747678.

Declarations

Ethics approval and consent to participate

The ethical approval was obtained from “The Ethics Committee Of The Faculty Of Dentistry at Ataturk University” (meeting date: 29.12.2022; meeting number: 12, decision no:97).

Each participant was informed individually about all the procedures to be performed and all participants signed a written consent form in accordance with the Helsinki Declaration of 1975 (2013 revision).

Consent for publication

All authors are agree for publication

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Özkal Eminoğlu, D. (2025). Evaluation of Plaque Removal by Triple-Headed Manual Toothbrush: A Randomized Controlled Clinical Trial [Data set]. Zenodo. 10.5281/zenodo.14747678.

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