Trisha E. O`Hehir, RDH
Toothbrushing instructions are an integral part of dental hygiene - second nature to the clinician. Textbooks, toothbrushing bro-chures, and even toothbrush packages stress the importance of bristle placement and toothbrush movement. But what do we tell our patients about the pattern to be followed? Where should toothbrushing start? How much time should be spent in each area? What do we really know about our patients` current toothbrushing patterns?
Gathering truly objective baseline data on toothbrushing patterns has been complicated by the need for informed consent from the patient. When you tell people you are going to watch how they brush their teeth, they often change what they do and how long they brush. It is no longer possible to gather this information without first telling the patient exactly what you plan to do.
Unsuspecting brushers tell us what we know
What little we do know about toothbrushing patterns and brushing times was reported in 1978 and 1979 by Drs. MacGregor & Rugg-Gunn. They used a two-way mirror and videotape to record actual toothbrushing of unsuspecting subjects.
The patients had agreed to participate in a dental study. But they were not told their brushing would be observed. They were simply told to go to the sink and brush their teeth before "beginning the study." Findings from this study proved to be quite interesting.
For these patients, toothbrushing began most often on the maxillary facial surfaces. The researchers observed a cross-arch start for most brushers. Right-handed brushers brushed first on the left side and left-handed brushers started on the right side.
Most adults and children brushed the facial surfaces of the front or left side first. The findings suggested that the area one starts brushing may receive more brushing than other areas. The erratic pattern observed was that the brusher returned several times to the first area brushed, which was a maxillary facial surface.
Many brushers neglected the lingual surfaces entirely. Those who did brush the lingual surfaces spent only 10 percent of their brushing time in that area, usually leaving it till last.
Overall, brushing times were reported to be generally less than a minute, frequently less than 30 seconds. Reported toothbrushing times range from 20 to 85 seconds, and little or no time was being spent on the lingual surfaces.
With the above findings in mind, consider this. The greatest accumulation of calculus and bacterial plaque is on the lingual surfaces of mandibular teeth. Clinical dental hygienists don`t need research to tell them that! There is a well known but never discussed index used by clinicians every day which evaluates the accumulation on lingual surfaces. Although subjective in nature, it takes no more than one second to perform, requires only a mouth mirror, and is quite accurate in determining case difficulty.
To perform this index, hygienists simply place the mouth mirror behind the lingual surfaces of the mandibular anterior teeth and quickly look at the accumulation. When used on patients arriving late for an appointment, it can determine just how late the hygienist is going to run as a result! Although not covered in hygiene textbooks, not taught is school, and not used in research, this mouth mirror index is widely used by clinicians every day.
As a result, hygienists are well aware that the greatest accumulation of plaque and calculus is found on the lingual surfaces of the mandibular teeth. Many patients are told to brush mandibular lingual surfaces first, going against all available support material on the subject, which suggests brushing maxillary facial surfaces first.
Despite research and knowledge of the heavy accumulation in this area, toothbrushing instructions focus very little attention on the lingual surfaces. Toothbrushing techniques primarily address the relationship of the bristles to the teeth and gingival tissues, as well as the direction of the brushing stroke. Today`s techniques stress the importance of pointing the bristles into the gingiva, attempting to reach just under the gingival margin. A gentle back-and-forth or scrubbing motion is the norm.
Demonstrations in the mouth are easier on the facial surfaces, sending patients the message to brush outside first. Diagrams in toothbrushing broc-hures demonstrate brush placement, but they do not stress beginning the process where deposits are most frequently found. The pattern of brushing is not even discussed.
In general, studies focus on brush placement and movement, but the pattern of brushing, including where to start, is not addressed. Dr. DeVore demonstrated overall reductions in bacterial plaque after patients received detailed oral hygiene instructions. However, despite reductions of up to 50 percent in most areas of the mouth, the mandibular right lingual section, often the last area brushed, if at all, showed only an 8 percent reduction.
The importance of achieving plaque-free surfaces through oral hygiene is well documented. Some researchers suggest complete removal of plaque every day or even every second day is more valuable than several inadequate brushings per day. Attempts to thoroughly remove plaque once per day may be enhanced by stressing a pattern of brushing that starts in the areas of greatest accumulation.
It is the hygienist who can influence the pattern of brushing with a simple message: brush inside first.
Trisha E. O`Hehir, RDH, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.
