Manual versus Powered Toothbrushes

Both manual and electric toothbrushes can effectively remove plaque if patients use correct technique and brush for an adequate time period (Figures 10‑11). Certain toothbrush designs, however, provide more effective removal than others. Some studies show oscillating-rotating electric brushes can be more effective at plaque removal than manual brushes. Electric toothbrushes were shown to be as safe to use as manual toothbrushes if used properly.

Figure 10. Manual Brush.
image showing a manual toothbrush
Image courtesy of Sunstar Americas
Figure 11. Power Brush.
image showing a power toothbrush
Image courtesy of Crest® + Oral-B®

There are many power toothbrushes available on the market. There are less expensive battery-powered toothbrushes for patients to try as their first power toothbrush. However, the professional toothbrushes have many more options then the battery-operated toothbrushes. For example, Procter & Gamble’s Oral-B® pro series electric toothbrushes have a red light that flashes in the handle when the patient presses too hard. We know it can be difficult for patients who have always used a manual toothbrush to switch to an electric toothbrush. I recommend if patients would like to switch from a manual to an electric toothbrush to temporarily remove all manual toothbrushes so the patient must use the electric toothbrush. We have found that the patient will go back to the manual toothbrush if it’s still in the vicinity, typically alternating between the two. Since we know that we need several weeks of practice to create a new habit, access to manual toothbrushes may prohibit a permanent change to electric. Realistically patients need to find a toothbrush that they will use for at least two minutes at least twice a day, as recommended by the ADA. Their favorite toothbrush may be a manual, battery-operated, or an electric toothbrush. The key is to find one that they like and will use daily to disrupt plaque and bacterial colonies.

Electric toothbrushes can be effective for all patients, particularly those with low manual dexterity or physical limitations. The larger handle may be better for patients who cannot grip the smaller manual toothbrush handles, e.g., patients with arthritis or stroke victims. The patient should be encouraged to try both manual and electric toothbrushes and determine which is best for them. However, the patient should be instructed to use the new toothbrush for at least four weeks, as it takes approximately 3-4 weeks for someone to develop a habit. Trying new dental products requires time to adapt to new habits.

I personally recommend when a patient would like to switch from a manual toothbrush to an electric toothbrush, they temporarily remove all manual toothbrushes from their home. I’ve found that patients will switch back and forth between the manual and electric toothbrush and not develop a habit with the electric toothbrush.

There are several manual toothbrushing techniques. They include the horizontal scrub, Bass, Stillman, Charters, and Fones, to name a few. The most popular method that an uneducated patient uses is the horizontal scrub. Unfortunately, gingival and enamel damage can occur with aggressive strokes and too firm of bristles. The Stillman method is used for massage and stimulation of the gingiva with a 45-degree angle of the bristles and a vibratory/pulsing method. The Charters method also involves a 45-degree angle with the bristles and a rotary or vibratory motion forcing the bristles interproximally. The Charters method can be recommended for orthodontic patients to clean ortho brackets and bands.

The preferred method for adults is the Modified Bass Method (Figure 12). This method was the first to focus on the removal of plaque and debris from the gingival sulcus with the combined use of the soft toothbrush and dental floss. This method is effective for removing plaque at the gingival margins and controlling plaque that leads to periodontal disease and dental caries. In the Bass technique, the toothbrush is positioned in the gingival sulcus at a 45-degree angle to the tooth apices. A vibratory action, described as a back-and-forth horizontal jiggle, causes a pulsing of the bristles to clean the sulcus. The term ‘modified’ indicates a final ‘sweep’ with the toothbrush toward the occlusal surfaces to remove debris subgingivally. Ten strokes are recommended for each area. This is the only toothbrush method that places the toothbrush bristles into the sulcus.

Figure 12. Modified Bass Method.
Modified Bass brushing method

For children, the rotary method called the Fones technique (Figure 13) is preferred since children do not have the manual dexterity for a more advanced technique, such as the Bass. The Fones technique is a circular method similar to the motion of the old rotary telephone. The teeth are clinched and the toothbrush is placed inside the cheeks. The toothbrush is moved in a circular method over both the maxillary and mandibular teeth. In the anterior region, the teeth are placed in an edge-to-edge position and the circular motion is continued. Children should adapt to this technique rather quickly.

Figure 13a. Fones Technique.
Modified Bass Technique
Figure 13b. Fones Technique - Anterior Teeth.
Fones Technique
Whichever toothbrush is used, the patient should be taught to remove plaque in a sequential order when brushing to make sure they don’t skip any surface areas of the enamel or exposed cementum. The patient should be shown in the mirror the proper technique and their instruction should also include brushing their tongue to remove debris and bacteria. The patient should show that they understand their oral hygiene instruction by demonstrating it back to the dental professional. A combination of oral and written instructions is always preferred. Studies have shown that too many instructions at one time is overwhelming for the patient, and they will not adopt new habits unless they understand and believe that they have value and are important.