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 Table of Contents  
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 20-26

Comparison of modified circular and natural toothbrushing methods in effectiveness of dental plaque removal and gingival improvement

Department of Preventive Dentistry, Faculty of Dentistry, Prince of Songkla University, Songkhla, Thailand

Date of Submission01-Jul-2019
Date of Decision16-Aug-2019
Date of Acceptance24-Aug-2019
Date of Web Publication25-Feb-2020

Correspondence Address:
Asst. Prof. Jaranya Hunsrisakhun
Department of Preventive Dentistry, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Songkhla 90112.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_175_19

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Aim: To evaluate the effectiveness in plaque removal and gingival improvement between the Modified Circular and the natural toothbrushing methods in 10- to 12-year-old children. Materials and Methods: A presented quasi-experimental study had a total of 124 fifth graders who were randomized into control and intervention groups. The examination used a structured questionnaire; gingival index (GI), plaque index (PI), and video recording were performed at baseline and follow-up. One oral examiner and one interviewer were blinded for the data collection. Both groups were trained to brush their teeth twice daily for 2 minutes. The intervention group was trained to brush using the Modified Circular and the control group was asked to brush using the same way they brush every day. The collected data were analyzed using demographic statistic, t-test and chi-squared test. Results: At baseline, no significant differences were observed in the mean PI and mean GI between the intervention group (PI = 2.37, standard deviation [SD] = 0.71; GI = 0.49, SD = 0.29) and the control group (PI = 2.26, SD = 0.64; GI = 0.52, SD = 0.29). At one-month follow-up, the intervention group had significantly lower mean PI (PI = 1.74, SD = 0.96) than the control group (PI = 2.30, SD = 1.18) (P < 0.004). The intervention group had a significantly lower mean GI (GI = 0.28, SD = 0.33) than the control group (GI = 0.51, SD = 0.40) (P < 0.002). Conclusion: The Modified Circular method can effectively remove plaque in 10- to 12-year-old children better than the natural toothbrushing method.

Keywords: Gingival Improvement, Plaque Removal, Toothbrushing

How to cite this article:
Hapsari I, Hunsrisakhun J. Comparison of modified circular and natural toothbrushing methods in effectiveness of dental plaque removal and gingival improvement. J Int Oral Health 2020;12:20-6

How to cite this URL:
Hapsari I, Hunsrisakhun J. Comparison of modified circular and natural toothbrushing methods in effectiveness of dental plaque removal and gingival improvement. J Int Oral Health [serial online] 2020 [cited 2022 Jan 18];12:20-6. Available from:

  Introduction Top

Dental caries is a worldwide disease that pursues people during their lifetime.[1] The Ministry of Health Republic of Indonesia in Basic Health Research 2018[2] showed that the DMF-T (decayed, missing, and filled teeth) index was 7.1 in Indonesia, with 45.3% of population having dental caries and 14% of the population having gingivitis. In Yogyakarta, 47.7% of the population had dental caries and 15.4% of the population had gingivitis. Both dental caries and gingivitis are caused by dental plaque or known as dental biofilm.[3],[4] In this situation, renewal of existing oral hygiene techniques is needed to improve oral health and prevent oral diseases.

Dental caries and gingivitis can be prevented by plaque control. Self-performed plaque removal by toothbrushing is the primary method to keep good oral hygiene.[5] Good oral hygiene habits, built especially in children, will protect the permanent teeth for a lifetime.[6]

An ideal toothbrushing method is the method that can work for the individual and can remove dental plaque without causing damage to the teeth, gingiva, or other tissues.[7],[8] Not one single known toothbrushing method can meet all of the criteria for an ideal toothbrushing method. Asadoorian[9] estimated that over 90% of people use their natural toothbrushing method that is personally built. Natural method is said to be able to remove dental plaque from the teeth surfaces but it has a possibility to cause damage to the hard and soft tissue.[10] People are less concerned with some areas of the teeth that are difficult to be seen directly and that are not affecting their appearance.[11]

Children aged 10–12 years are in late mixed dentition,[12] which is the transitional period from milk teeth in children to permanent teeth in adults.[13] Children in the age of 10–12 years in Indonesia use the natural method of brushing and they still have high plaque level.[2] This age group needs to improve their brushing quality to prepare for the adult phase. However, a limited number of studies recommend toothbrushing methods in children in the late mixed dentition age group. A recommended toothbrushing method for this age group was not found in Indonesia. However, in the early mixed dentition age group, the horizontal method was recommended.[14] The horizontal method is easy to learn and practice by children,[15] but it is not good enough in cleaning the proximal and gingival sulcus areas of the teeth. The horizontal method is strongly related to gingival recession and tooth abrasion.[16] A literature review by Wainwright and Sheiham[17] showed that the Bass and modified Bass methods were the most frequently advocated methods for adults, which are good in plaque removal of the teeth and underneath the gingiva.[18],[19] Modified Bass method was said to be a more effective method in removing dental plaque than other methods.[20] However, children have difficulty placing the brush in the gingival sulcus position and have difficulty accomplishing the proper motion.[4],[21]

Delivering Better Oral Health[22] stated there is no toothbrushing method that is superior to another method and a person’s existing method may need to be modified to clean all tooth surfaces. To enhance brushing on all surfaces of teeth, modifications can be made to the technique of toothbrushing.[23] A combination of toothbrushing techniques is considered a good method for plaque removal.[19] Different surfaces of the teeth need different techniques of brushing.[11] This research introduces the new brushing technique, Modified Circular technique, which combines and modifies from the existing brushing techniques. It uses small circular motion with position of the brush slightly reaching underneath the gingiva by placing at nearly 45° angle to the apex of the teeth [Figure 1]. This technique is similar to the Bass technique and Stillman methods in terms of positioning at 45° angle. But it is different from the Bass technique, which applies short back and forth movement, whereas it is different from the Stillman method, in which the bristles are partially located on the gingiva. This new method is potentially giving benefit for children in the age of 10- ‑to 12 ‑year ‑old. The Modified Circular does no need rolling motion like Modified Bass that causes difficulty for children to replace the bristle in gingival sulcus position. The movement of the brush in Modified Circular method is not short back and forth like the original Bass method that has possibility for children to gradually switch the movement of the brush from the short stroke to be a horizontal long stroke. The circular motion of the brush in Modified Circular method is done by producing small circular for each jaw and it is easy to be controlled to avoid the gingival recession. This movement is different with the Fones method which use circular movement that reaching upper and lower jaws in one motion that increase the possibility of gingival recession. So this technique is considered less harmful than the Fones method. These actions are performed mainly at all areas except the lingual and palatal area of anterior teeth, the teeth should be brushed in vertical technique to produce effective plaque removal.[14] Horizontal technique is applied for the occlusal areas. It is needed to examine whether Modified Circular method is appropriate for the children in the age range 10–12 years.
Figure 1: Motion and position of the brush in the Modified Circular method

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This study aimed to evaluate the effectiveness in plaque removal and gingival improvement between the Modified Circular and the natural toothbrushing methods in children who were 10–12 years of age.

  Materials and Methods Top

The research used the quasi-experimental study design. Data were gathered from two groups of subjects from two state elementary schools in the same cluster in one subdistrict in Yogyakarta, Indonesia. The two schools were similar in socioeconomic status and the numbers of students were selected based on the data and recommendation of the Technical Education Service Unit of Yogyakarta. All of the fifth graders of the selected schools participated in the study. With the coin flipping method for randomization, one school was allocated to be the intervention group and the other was the control group. The participant willing to join the study had been informed about the research protocol and signed the consent forms.

Sample size was calculated using the sample size calculator software by PS version 3.1.2 by William D. Dupont and Walton D. Plummer[24] using t-test for paired and independent groups with alpha 0.05 and power 0.8. The highest number of the result of sample size calculation was chosen to cover the needs of sufficient subjects for the examinations. The number of subjects needed in this study was 58 children each group. Similar study[25] previously conducted experienced the loss of follow-up of 5%. To anticipate the loss of follow-up in this study, the sample size for each group was increased 5% by adding three children in each group. So the sample size for this study was 61 children each group. The total sample size needed in this study was 122. In fact, the number of participants for each school was 62 and the total participants that followed the study was 124. All participants from both schools were recruited in this study.

The inclusion criteria for this study were children in the age range of 10–12 years who were willing and permitted by their parents or guardian to join the study. The exclusion criteria were children diagnosed as having mental retardation, autism, and any late mental development or children who were undergoing antibiotic medical therapy, having orthodontic appliances, or using antiseptic mouthwash for daily use.

This research was a single-blinded study in which the examiner was blinded to the allocation of the subjects. The examiner was not told which school was the control group and which school was the intervention group. Contamination bias that might occur in this study had been addressed by the use of two different schools for each group so that the participants between groups did not influence each other. The participants from both selected schools were given information about the study by researcher and given informed consent forms for the participants and their parents/guardians to be signed if they were willing to join in the study. This was carried out for both schools from July 27 to July 31, 2017. The study began with the baseline data collection by examining the participants using the gingival index (GI), plaque index (PI), a questionnaire, and video recording on August 1 and August 2, 2017. Then, it was continued with the training of the participants on how to improve oral hygiene on August 9 and August 10, 2017. Each group was instructed to brush their teeth twice per day and sing a song in their mind while brushing to control the brushing duration to be of at least 2 minutes. The intervention group was trained to brush their teeth using the Modified Circular method, whereas the control group was asked to brush their teeth using the usual way they brushed every day. The intervention was started after training and lasted for one month (August 10 to September 11, 2017, for the control group and August 11 to September 12, 2017, for the intervention group).

Monitoring was implemented in the intervention group once a week in a large number of participants to remind them how to correctly perform the Modified Circular method and to ensure they brushed their teeth correctly using the intervention method. At the end of the first week after training, suggestions were given only to the participants who did the method incorrectly. From the second through the fourth week, the participants were observed without suggestions. Monitoring was not implemented in the control group to prevent the participants in the control group from changing their brushing method when they were aware that they were being observed in the monitoring period, whereas in this study, participants in the control group were expected to brush their teeth with natural methods as they brush their teeth each day. The researcher provided the toothbrushes (Dr. White Clean soft produced by PT Megah Buana Pancarona, Banten, Indonesia) and toothpastes (Kodomo Toothpaste produced by PT Lion Wings, Jakarta, Indonesia) for both the groups to be used during the intervention period. Follow-up data collection was carried out after the one-month intervention period by examining the same data as the baseline on September 11 and September 12, 2017.

Personal information, toothbrushing habits, eating habits, and dental attendance of the participants were collected using a structured questionnaire. The questionnaire was made by the researcher and had been evaluated for the content, scoring criteria, and language compatibility by three experts from the Faculty of Dentistry, Prince of Songkla University using the face validity. The back-translation technique had been used to ensure the quality of the questionnaire between the English and the Indonesian language versions. Examination of the gingival condition used the gingival index by Silness and Loe[26] by examining all of the gingiva on the buccal, lingual/palatal, mesial, and distal areas of the teeth. The plaque levels of the participants were measured using the Turesky modification of the Quigley–Hein index[27] by painting all of the exposed tooth surfaces with disclosing solution. The participants were asked to rinse one time and then the facial and lingual surfaces of the teeth were examined except the third molars. Video recordings were taken to observe the technique, duration, and systematic toothbrushing of the participants. No mirror was used during the video recording.

Statistical analysis: All of the data were analyzed using the Statistical Package for the Social Sciences (SPSS) program (SPSS, Chicago, Illinois). Descriptive statistics was used to evaluate the demographic data. Chi-squared and Fisher exact tests were used to investigate whether the distributions of categorical variables differed from one another. The data gathered from the control and the intervention groups were compared using independent t-test, Mann–Whitney U-test, and paired t-test. A two-sided significance level of 0.05 was applied.

  Results Top

The number of participants enrolled at the beginning of this study was 62 children each for the control and the experimental groups. None of the participants were excluded; however, two in the control group and four in the intervention group were lost to follow-up on the day of data collection because of sickness or family occasion. Using the intention-to-treat method, the data were analyzed following the original number allocated, which was 62 in each group. The missing values at the time of follow-up were replaced using the last value obtained. In this case, the baseline values were used. Calibration was used before collection of the baseline data. [Table 1] shows that the ages of the participants and the percentages of gender between the control and the intervention groups were not significantly different (P > 0.05). Toothbrushing, eating habits, and dental attendance of the participants were also not significantly different (P > 0.05). In this study, all of the participants in the control group could follow the protocol to brush their teeth using the natural method. In the intervention group, 79% of the participants followed the protocol to systematically brush their teeth using the Modified Circular toothbrushing method.
Table 1: Demographic data, toothbrushing practices, and eating habits

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Plaque index: Overall [Figure 2] and each sextant [Table 2] mean of PI for the two groups at baseline was not different (P > 0.05) except the right and left upper lingual posterior surfaces that had statistically different mean PI (P < 0.05) with a higher value of dental plaque in the intervention group. At the one-month follow-up, the overall mean of PI in the intervention group was significantly lower (P < 0.05) than that in the control group. Furthermore, from the analysis of each sextant, most sextants were significantly different (P < 0.05). The proportion in the level of plaque reduction compared with the baseline values within each group showed that the intervention group had better improvement (26.7%), whereas the control group had only 1.6% improvement [Table 3]. When only the brushed facial areas were compared between the groups, the areas brushed using the Modified Circular method had a significantly lower plaque level than the areas brushed with the natural method (P < 0.05).
Figure 2: Comparison of mean plaque and gingival indexes of the control and intervention groups at baseline and one-month follow-up

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Table 2: Plaque levels in buccal and lingual surfaces of each sextant

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Table 3: Changes in the plaque index and gingivitis index within each group

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Gingival index: At baseline, no differences were observed in the mean GI [Figure 2] between the groups (P > 0.05). At the one-month follow-up, the intervention group had a significantly lower mean GI than the control group (P < 0.05). The proportion of each group in gingival improvement showed that the intervention group had a 43% improvement, whereas the control group had only 1.5% improvement [Table 3].

  Discussion Top

In Indonesia, oral health problems among the 10- to 12-year-old children are still high.[2] As no formal toothbrushing method is recommended for this age group, they brush their teeth according to their own personal standard. However, one study showed that although the natural toothbrushing method can clean the tooth surfaces, it can cause gingival recession and tooth abrasion.[10] A similar study by Poyato-Ferrera et al.[19] previously conducted in students aged 18–30 years at a secondary school showed that the modified Bass method was significantly more effective in plaque removal than the normal method. A study by Giri[28] performed in 60 auxiliary workers showed that the modified Bass method was more effective to remove dental plaque than the normal method. It showed that certain methods of toothbrushing can provide better performance for teeth cleaning. People’s existing methods of brushing may need to be modified to clean all tooth surfaces.[22]

Some similar studies had been conducted, such as a study by Smutkeeree et al.,[25] which compared two groups of visually impaired children aged 10–12 years using horizontal technique and Modified Bass by brushing twice daily at least 2min showing no difference in plaque removal. A study by Ceyhan et al.[29] compared two groups of preschool children using horizontal scrub and Fones methods, which showed that no differences in plaque level were found in the one month after training. A study by Ilyas et al.[30] comparing three groups of children aged 8–11 years that used Fones, Modified Bass, and horizontal scrub methods showed that Modified Bass was the most effective method in the reduction of plaque score. Another study by Joybell et al.[31] comparing two groups that used Fones and Modified Bass methods resulted in no difference in plaque level between the groups. Patil et al.[32] compared three groups using horizontal scrub, Fones, and Modified Bass methods and reported no difference between those three groups in 24h follow-up plaque scores. Research by Robinson[33] also found no significant differences between the Bass method and horizontal scrub method in the fifth and sixth graders. Comparison with other studies are difficult to interpret as the techniques and protocols were different; however, it may indicate that no specific method is the best for all groups.

There is still a need to find the ideal toothbrushing method for the late mixed dentition group. This study introduced the Modified Circular method, which combined the Bass, Fones, vertical, and horizontal methods in order to diminish the obstacles of these methods, and at the same time, preserve the advantages of these methods to be appropriate for each tooth surface.

A one-month intervention period in this study was enough to show a change in oral hygiene. Dental plaque can be seen to form from the 1st h after the last cleaning of the teeth.[34] The time necessary to develop gingivitis varied from 10 to 21 days, although oral hygiene practice can produce healthier gingiva within 5–10 days.[35]

Standardized calibration by an expert for the GI (κ = 0.73) and PI (κ = 0.77) was categorized as good.[36] The intra-rater calibration of the GI (κ = 0.76) and PI (κ = 0.79) was also categorized as good. These κ values showed that the examiner had reliability that means consistency in the assessment and the data collected by the examiner were valid.

The Modified Circular method was created to meet the criteria for an ideal toothbrushing method for children aged 10–12 years by applying small circular motions with the position of the brush slightly reaching underneath the gingiva combined with the vertical and horizontal methods. This circular movement is expected to be easy to learn and practice by children, which is similar to the method stated by Fones.[37] In this study, most participants (79%) in the intervention group could systematically perform the Modified Circular method with the correct position and motion while brushing. This situation showed that the Modified Circular was easy and applicable toothbrushing method for children aged 10- to 12-year-old. In addition, greater plaque reduction was found in each sextant of the intervention group, which may imply that this new method might be appropriate for most sextants.

With no differences in the plaque and gingivitis conditions at baseline, the effectiveness of the Modified Circular method in removing dental plaque and decreasing gingival inflammation was significantly shown at one-month follow-up compared to that of the natural method. This study also showed a decrease in gingival inflammation of nearly 43% in the intervention group compared with the control group in which gingival inflammation decreased only by 1.5%. Also, the plaque reduction in the intervention group was higher (26.7%) than the control group as a whole (1.6%). The reduction of plaque and gingivitis in the intervention group fulfilled the American Dental Association (ADA) threshold that requires 15% plaque reduction and 15% gingivitis reduction.[38] However, the reduction of plaque and gingivitis in the control group did not satisfy the ADA threshold.

The higher reduction in the levels of plaque and gingivitis in the intervention group compared to the control group was possibly due to several factors.

  1. From a comparison of the brushed areas at one-month follow-up, better plaque removal was clearly shown in the intervention group. It may be explained that the position of the brush in the Modified Circular method reached underneath the gingiva, with the small circular motion caused the brush to make contact with the tooth and the gingiva, which produced better tooth cleaning and healthier gingiva compared with that in the natural toothbrushing method.

  2. The once-a-week observation and providing suggestions at the end of the first week in a large number of participants in the intervention group helped controlling them to appropriately do the Modified Circular method. This possibly increased the awareness of the participants in the intervention group knowing they were being studied. However, a comparison between the intervention and the control groups showed no differences in the frequency and duration of brushing in this study.

  3. The Modified Circular method with the systematic brushing possibly decreased the number of unbrushed tooth surfaces, whereas the natural toothbrushing group was not taught systematic toothbrushing and they still had unbrushed surfaces of the teeth.

This study revealed that the natural toothbrushing practice in children aged 10–12 years should not be recommended because this method did not effectively remove dental plaque or reduce gingivitis. Most of the children forgot to brush the lingual sites and left the dental plaque unremoved, which increased the risk of development of dental caries and gingivitis.

The strength of the study was the quasi-experimental design, which was able to reflect the real situations. Furthermore, the researchers were able to limit the effects from confounding variables and reduced bias of the examiners from the single-blinded allocation of the samples. Also, the inter- and intra-calibration achieved a good level. The limitations of this study were that the training course for the control group did not encourage the students to perform systematic brushing and there was no monitoring. From this study, we suggest to conduct a further study on the long-term effects of the Modified Circular method or to add monitoring in the control group as well as to compare the effectiveness of the Modified Circular method with the methods recommended in adults or younger children.

In conclusion, the effectiveness of the Modified Circular method showed significant improvement in plaque removal and gingival health compared to the natural toothbrushing method. This study suggested that the combined toothbrushing method was a better choice for children aged 10–12 years in aspects of cleanliness, easiness, and simplicity compared with the natural method.

Ethical policy and institutional review board statement

The research protocol was approved by the institutional review board of Prince of Songkla University (EC6004-12-P-LR) and Gadjah Mada University (KE/FK/0773/EC/2017). The study was registered in (NCT03547531).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by the Graduate School Research Funding and the Faculty of Dentistry Research Funding, Prince of Songkla University, Thailand.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]

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