I Scream for Ice Cream

by Anne Nugent Guignon, RDH, MPH

Dessert anyone? Raise your hands high! Wow, I can see virtual hands popping up all over the place. Everyone is eager to lure their taste buds into a gastronomical paradise.

How many of you like ice cream? How about some other type of sweet frozen concoction? OK, now that we have that settled, let’s pretend that power brushes are like frozen desserts and we’re in charge of picking out an extraordinary dessert for every special person in our lives.

Does everyone you know like chocolate ice cream? What if your best friend from dental hygiene school likes almonds and your favorite cousin can’t stand coconut? Don’t forget your fabulous neighbor - the one who takes care of your adorable four-pawed companion while you’re off to the annual RDH Under One Roof conference - she adores lemon sorbet and wouldn’t cross the block for a spoonful of the most exclusive super-rich totally high calorie chocolate dessert on the face of the earth.

Can you imagine which of your friends would nibble daintily on dessert in a cup and which ones would love to lick ice cream propped atop a crispy waffle cone? Which other friends would be delighted to try the same flavor. Others will prefer a different taste or texture. Each of us has a friend who has never met a piece of chocolate he or she didn’t like; my friend Kristen is like that. As for me, only dark European chocolate with at least 70 percent cocoa crosses my lips. Our needs and preferences are all different when it comes to dessert and I believe that the basis for our professional recommendations in the clinical setting deserves at least as much consideration, if not more, as what we select to satisfy our sweet tooth.

Every time I present a continuing education course that includes information about ultrasonic scaling or power brushing I conduct an informal poll and ask who wants to go back to the days before power brushes or ultrasonic scalers were readily available. No one ever raises his or her hand. Individually and collectively we have all witnessed the dramatic benefits that can happen when power technology is applied appropriately and effectively to disrupt biofilm.

As far-fetched as it might seem, picking the most appropriate power brush for our patients is much like selecting a dessert they will enjoy to the last bite. Stacks of research papers demonstrate that power brushes used properly can have a dramatic and positive effect on disrupting plaque biofilm and often provide an outcome that far surpasses what can be obtained using a manual brush.^1-3

Some dental professionals believe they can deliver the same outcome with a hand brush as a power brush. While this may be possible for those with an exceptional level of dexterity (such as hygienists), most clinicians trust that power brushes deliver more bang for the buck, especially if the user has received specific hands-on training with power brushes.

Interestingly enough, a survey conducted in 2003 by MIT found that the number one invention that people did not want to live without was their toothbrush!⁴ The toothbrush beat out the automobile, personal computer, cell phone, and microwave. How can we use this information to our advantage?

Despite the widespread availability of power brushes, as well as the remarkable improvements in technology, estimates indicate that only about one in five people take advantage of the benefits derived from improved biofilm disruption via power brushes.

No one knows more than a dental hygienist just how sticky biofilm is or how hard it can be to remove a pathogenic pile of slime, even with the most sophisticated power scaler.^{1,2, 5-7} People are living longer. More are taking multiple medications that dry their mouth out. An increasing number of patients have arthritic disorders or memories that bounce in and out of real time, which affect both dexterity and compliance. Top the problem off with a caregiver who would really rather change an adult diaper than brush someone’s teeth since they believe that all teeth decay eventually.

What about our bulletproof teens and pre-teens that can’t take their hands off the computer, cell phone or iPod long enough to brush their teeth before they steal another hot teenage kiss? Then we have the challenge of the twenty- or thirty-something rising corporate stars who want to look fabulous but are just too busy to take two minutes to brush, much less do anything else to maintain good oral health. After all, their teeth are sealed and straightened, so what’s all the fuss?

Of course, there’s the harried housewife, the always over-budget single parent, the senior executive who can’t seem to get home before eight at night or the second grader who has teeth coming in and out every other week. Oh, I nearly forgot the patient who whines about the exorbitant cost of a power brush while they clutch keys to a $60,000 car in their hands.

Today’s marketplace is crowded with dozens of power brushes. The choices range from disposable battery-operated rotating brushes to sophisticated rechargeable power brushes, built to be in service for years. Many power brushes are available for purchase on the Internet, as well as in grocery stores, pharmacies, and select high-end retail establishments. Some products can only be obtained through dental offices. Prices for power brushes vary considerably and reflect the sophistication of the technology, quality of construction, product warranty and the number of unique features incorporated in a specific brush. Some manufacturers offer special pricing for dental professionals.

Certainly, there are some similarities within the power brush arena, but the best way to sort through the piles of research and voluminous product claims is to study the features and benefits of a variety of power brushes. Power brushes can feature mechanical debridement alone or in combination with either sonic action or a combination of sonic and ultrasound activity.^8,9

It is impossible to discuss every brand of power brush that is available today within the scope of one column; however, mechanical brushes and their features can be classified according to the action of the brush head or the underlying technology that supports the power brush design.

The rechargeable Rotadent power brush by ProDentec is available exclusively through dental offices and has a brush head that rotates in one direction at a uniform rate. It features interchangeable brush heads made with uniquely designed microfilaments. Brush head configurations include hollow cup, short pointed tip, and elongated tip designs. Biofilm disruption occurs when the rotating brush head comes in direct contact with the tooth surface.¹⁰

The Rotadent is lightweight and has a slim, angled neck that makes it particularly appealing to patients with a limited opening. Patients with dexterity or pinch-grip issues may need assistance to change out the various brush heads. From a cost perspective, the Rotadent is at the high end of the price range.

The Crest Spin Brush series is an example of a brush that uses a combination of mechanical brush head designs to remove plaque when applied directly to the tooth surface.¹⁰ The nine different models, shown on the Crest Spin Brush website, vary according to brush head design. Spin Brushes come either with an oscillating brush head and bristles that move up and down or a spinning head that is designed with either stationary ‘V’ cut bristles or multilevel bristles. There are both single speed and two-speed models and the brush heads are replaceable. Most use AA batteries but there is one rechargeable unit.

Spin Brushes are inexpensive and can be the perfect introduction to power brushes for children, patients with limited financial resources, or those who need proof that power brushes work before committing to a more sophisticated higher priced device. According to the Web site, these brushes range from $5 to $12, depending on the features, and can be found in many retail outlets.

The Oral B Triumph featuring the wireless Smart Guide is the company’s newest contender in the power-brushing world. The small round brush head oscillates and pulsates and the remote display features information sent via microchips imbedded in the brush handle. Users can see their actual brushing time and are alerted when they need to replace the brush or to use a lighter touch, valuable feedback for a new power brush user.

This updated version of the Triumph brush, along with previous models, is easy to find online and in retail establishments. The price varies according to the model and its features, but the cost of a new Triumph with the Smart Guide is consistent with other high-end power brushes.

Fifteen years ago, the Sonicare brush brought a new dimension to the power tooth-brushing world by coupling mechanical debridement with sonic technology to create fluid dynamics that could disrupt more plaque biofilm.^11-15 This novel approach caught on rapidly. Numerous research studies have since supported the benefits of power brushes that use sonic vibrations. A brand new Sonicare brush, called the FlexCare, was introduced last August at the RDH Under One Roof conference.

The FlexCare is an entirely new Sonicare design from the inside out. It took several years and intensive research and dramatic design improvements to develop an entirely new product. The handle is slimmer, more ergonomic and lightweight, and features a slender, easy-to-clean snap-on head. There are three different brushing modes and overall brush vibration is dramatically reduced due to changes in the internal vibratory mechanism. This is the first brush with a built-in brush head sanitizer. So Sonicare lovers, you are in for a real treat with this new brush which is available via professional dispensing or select retail establishments.

Don’t you just love it when scientists get the itch to take a product in a different direction? Well, that is exactly how the Ultreo brush came about. Scientists adept in sonic brush technology teamed up with a physicist who is an expert in ultrasound. Four years later a new brush based on a combination of sonic and ultrasound technology entered the power brush arena.

The Ultreo, launched in February 2007 at the Chicago Midwinter meeting, looks like a traditional power brush from a distance. But close inspection reveals a brush head that looks quite different. The small orange rectangle in the middle of the head is actually a medical grade silicone waveguide that sits right above the piezo electric transducer, which is embedded in the brush head housing. Ultrasound is transmitted from the back of the brush head through the waveguide into a population of gently expanding and contracting bubbles that disrupts plaque biofilm. Emerging research indicates that the addition of ultrasound may indeed enhance our ability to disrupt biofilm beyond the bristle tips.¹⁶

Due to this change in brush head design it is more important than ever to have a light touch when placing the bristle tips on the tooth surface. The Ultreo is remarkably quiet compared to other power brushes in today’s market. Available through dental offices, online and select retail establishments, the Ultreo is new, different and deserves your attention.

Our Job: Narrow the Choices

As the power toothbrush arena grows more and more interesting, we have a lot of work to do. We have a serious responsibility to recommend the right power brush for our patients, not just suggest the one that we personally use on a daily basis. We must think about additional features; consider the size, diameter, shape and overall weight of the brush handle. A seven year old may be more comfortable with a power brush designed with a petite hand in mind. The arthritic patient will appreciate a lighter weight handle that has a textured or soft gripping surface.

The ease and placement of the power button can make a difference. Again, an arthritic patient needs a soft, easily manipulated button. Years ago, the buttons on the handle of a popular power brush made it nearly impossible to go through an entire brushing cycle without turning it off prematurely.

Vibration and noise are other key considerations, which can have an effect on whether or not our patients will follow our recommendation to include power brushing in their daily routine. Certain power toothbrushes create so much vibration that those troubled by vertigo or motion sickness find these types of brushes unpleasant to use.

Brush head size and configuration are important. Most men prefer a larger brush head that has a more traditional look or feel. Men tend to hold the power brush handle with a death grip, press down on the bristles with too much force and use a back and forth strokes similar to a manual brush. Encourage your patient to relax and guide the brush along the gum line with a light touch, letting the brush do the work. Being able to dispense a product at the time of an appointment can have a very positive impact and allow us to customize oral care instruction at the most personal level.

Also consider how easy or difficult it is to replace the brush heads or keep them clean. Patients who can pick up their replacement heads when they’re in for a dental hygiene visit appreciate the convenience at a competitive price and are more likely to replace worn out heads in a timely fashion.

Finally, the overall price, warranty and product reliability are important to us as professionals, as well as our patients. A power brush purchase is a big deal for many patients, especially first timers. It represents a commitment to change, and it is an investment in the future of their oral health.

Today’s real challenges are recommending the right product for the right reasons, making sure our patients know how to use the product correctly, and sharing our enthusiasm over the change. In order to help our patients move forward we must set aside our personal preferences, step out of our comfort zones, and learn about a variety of devices so we can customize our recommendations in the most professional manner. Of course, don’t forget to enjoy your dessert.

References

1. Haffajee AD, Smith C, Torresyap G, Thompson M, Guerrero D, Socransky SS. Efficacy of manual and powered toothbrushes (II). Effect on microbiological parameters Clin Periodontol. 2001 Oct; 28(10): 947-54.
2. Scientific American. Emerging Trends in Oral Care. New York: Scientific American, Inc., 2002: 1 - 30
3. Kugel G, Boghosian AA. Effects of the sonicare toothbrush for specific indications. Compend Contin Educ Dent. 2002 Jul;23(7 Suppl 1):11-4.
4. http://web.mit.edu/newsoffice/2003/lemelson.html. Accessed July 2007
5. Herremans K. Ultrasonic Periodontal Debridement. In Concepts in Nonsurgical Periodontal Therapy. New York: Delmar Publishers, 1998: 320 - 343.
6. Kwan JY. Enhanced periodontal debridement with the use of micro ultrasonic, periodontal endoscopy. J Calif Dent Assoc. 2005 Mar;33(3):24-8.
7. Arabaci T, Cicek Y, Canakci CF. Sonic and ultrasonic scalers in periodontal treatment: a review. Int J Dent Hyg. 2007 Feb;5(1):2-12. Review.
8. Sharma NC, Lyle DM, Qaqish JG, Galustians J. Evaluation of the plaque removal efficacy of three power toothbrushes. J Int Acad Periodontol. 2006 Jul;8(3):83-8.
9. Ruhlman CD, Bartizek RD, Biesbrock AR. Comparative efficacy of two battery-powered toothbrushes on dental plaque removal. J Clin Dent. 2002;13(3):95-9.
10. Hope CK, Wilson M. Comparison of the interproximal plaque removal efficacy of two powered toothbrushes using in vitro oral biofilms. Am J Dent. 2002 Nov; 15 Spec No:7B-11B.
11. Hope CK, Petrie A, Wilson M. In vitro assessment of the plaque-removing ability of hydrodynamic shear forces produced beyond the bristles by 2 electric toothbrushes. J Periodontol. 2003 Jul;74(7):1017-22.
12. Hope CK, Wilson M. Effects of dynamic fluid activity from an electric toothbrush on in vitro oral biofilms. J Clin Periodontol. 2003 Jul;30(7):624-9.
13. Heersink J, Costerton WJ, Stoodley P. Influence of the Sonicare toothbrush on the structure and thickness of laboratory grown Streptococcus mutans biofilms. Am J Dent. 2003 Apr;16(2):79-83.
14. Pitt WG. Removal of oral biofilm by sonic phenomena. Am J Dent. 2005 Oct;18(5):345-52.
15. Brambilla E, Cagetti MG, Belluomo G, Fadini L, Garcia-Godoy F. Effects of sonic energy on monospecific biofilms of cariogenic microorganisms. Am J Dent. 2006 Feb;19(1):3-6.
16. Mourad PD, Roberts FA, McInnes C: Synergistic use of ultrasound and sonic motion for removal of dental plaque bacteria. Compend Contin Educ Dent 28:354-8, 2007.

About the Author

Anne Nugent Guignon, RDH, MPH, is the senior consulting editor for RDH magazine. She is an international speaker who has published numerous articles and authored several textbook chapters. Her popular programs include ergonomics, patient comfort, burnout, and advanced diagnostics and therapeutics. Recipient of the 2004 Mentor of the Year Award, Anne is an ADHA member and has practiced clinical dental hygiene in Houston since 1971. You can reach her at [email protected] or (832) 971-4540, and her Web site is www.anneguignon.com.