|Year : 2010 | Volume
| Issue : 2 | Page : 213-217
|Role of dentifrice in plaque removal: A clinical trial
A Jayakumar, H Padmini, A Haritha, Krishnanjaneya Pathakota Reddy
Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh, India
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|Date of Submission||08-Mar-2009|
|Date of Decision||23-Jun-2009|
|Date of Acceptance||23-Jan-2010|
|Date of Web Publication||22-Jul-2010|
| Abstract|| |
Background: The precise role of dentifrice in plaque removal has been debatable. While a considerable volume of literature attributes several beneficial properties and glorifies the role of dentifrice, a small body of researchers questions its efficacy. Lingering doubts are emerging about the plaque removal efficacy of toothpastes and probably a time has come to reassess its role in plaque removal.
Aim: The present study is used to evaluate the plaque removal efficacy of dentifrice alone during the manual brushing of teeth.
Materials and Methods: In a double blinded 2 Χ 2 crossover study design, 42 subjects had brushed randomly with or without dentifrice under supervision, with a standard dentifrice and toothbrush, after 48 hours of plaque accumulation, for two minutes.
Results: Plaque reduction with dentifrice was 57.35% and without dentifrice was 66.19%. This 9% difference was statistically significant ( P ≤ 0.001).
Conclusion: Dentifrice use does not enhance plaque removal when used in conjunction with a toothbrush, and instead, may marginally lessen the brushing effect. The role of a toothbrush appears to be more crucial in the maintenance of oral hygiene.
Keywords: Dentifrice, tooth brushing, plaque
|How to cite this article:|
Jayakumar A, Padmini H, Haritha A, Reddy KP. Role of dentifrice in plaque removal: A clinical trial. Indian J Dent Res 2010;21:213-7
It is widely accepted in dentistry that plaque containing a combination of pathogenic microorganisms is the principal etiological factor associated with periodontal disease. Since Loe's experimental gingivitis study,  thorough plaque control has been considered essential to control and prevent gingival and periodontal disease. Supra gingival plaque control is critical in preventing both initial gingivitis and periodontal disease in later stages.  Mechanical tooth cleaning by means of a toothbrush and a dentifrice remains the most reliable and common method for controlling supra gingival plaque. ,
|How to cite this URL:|
Jayakumar A, Padmini H, Haritha A, Reddy KP. Role of dentifrice in plaque removal: A clinical trial. Indian J Dent Res [serial online] 2010 [cited 2013 Dec 7];21:213-7. Available from: http://www.ijdr.in/text.asp?2010/21/2/213/66629
Dentifrices are supposed to help in minimizing plaque buildup, strengthening teeth against caries, removing stains, removing food debris, and freshening the mouth. , Dentifrices containing anti-plaque and anti-inflammatory agents would also enhance plaque removal and help in overcoming the manual or mechanical shortcomings of brushing. 
Most of the studies that evaluate the efficacy of a dentifrice in plaque removal and those that assess different toothbrush designs, were done by comparison of the test product with the control. In such studies, the observed plaque reduction score could be due to the combined use of toothbrush and dentifrice, wherein, it was difficult to distinguish the precise contribution of either toothbrush or dentifrice.
Studies that attempted to define the precise role of dentifrices in plaque removal during mechanical tooth brushing are inconclusive. One study  stated that brushing with a dentifrice removed more plaque than brushing without it. Another study  found no difference between brushing with or without a dentifrice; in another study by Binny et al.,  and Paraskevas et al.,  brushing without a dentifrice found more plaque reduction than brushing with a dentifrice. A recent study  showed that the use of a dentifrice did not contribute to additional plaque removal during manual tooth brushing and concluded that the mechanical action provided by the toothbrush is crucial in plaque control. Although each of the above-mentioned studies differs in factors related to the study methodology, the overall result is indecisive.
The present study was undertaken keeping in view the conflicting role of dentifrices and the inconclusive evidence of its role when used in conjunction with tooth brushing. The aim of the present study is to delineate the actual role of the dentifrice and demystify the hype associated with the role of toothpaste.
| Materials and Methods|| |
The study population consisted of 52 student volunteers of Sri Sai College of Dental Surgery, Vikarabad, India. The students were screened for suitability, which included full mouth dental examination to exclude severe periodontal disease and restorative-related problems.
Adults older than 18 years of age, who had at least five evaluable teeth per quadrant, were included in the study.
Individuals with gingival and periodontal problems, caries and oral lesions, use of antibiotics in the previous three months, habituated to the use of mouth rinses, use of powered toothbrush at home, hypersensitivity to the dentifrice, use of any medications that affect the periodontal condition of the subject, and physically handicapped were excluded from the study.
After screening, the outline and purpose of the study was explained to the subjects and they signed an informed consent form. The study was approved by the Institutional Ethics Committee. The study period lasted for 30 days.
The study was conducted in a 2 Χ 2 crossover fashion with examiners masked and the participant unaware of what dentifrice and toothbrush they were using. All subjects had to undergo two sessions of brushing in a crossover manner. In one session, they had to brush with a dentifrice and in another session without a dentifrice. The brushing order was randomized. The method of randomization and allotment to either of the groups was done by the random selection of 21 numbers out of 42 by a different examiner (KR). Thus two groups, A and B, were made. Allotment of groups that had to use or not use dentifrice in the first session was decided by a coin toss.
The study was designed in a manner, such that, 5% true difference in plaque reduction was observed between brushing with and without a dentifrice, with a standard deviation of 15%, 80% power and an alpha error of 0.05.
[Additional file 1]
The subjects were given a manual toothbrush and a commercially available, commonly used dentifrice, with a Relative Dentin Abrasivity (RDA) value of 68 and a familiarization period of two weeks was allowed. This familiarization period was to facilitate transition from their previous toothbrush and dentifrice to the ones provided for this study. The dentifrice was a commonly used brand procured from the local market. On the fifteenth day after routine morning brushing, the subjects were asked to abstain from all oral hygiene measures for 48 hours. These two days permitted the plaque to accumulate on the tooth surface without any hindrance. At the end of the 48-hour period, prebrushing assessment of the plaque was done (PH) using the Quigley-Hein  method, modified by Turesky,  and further modified by Lobene.  Prior to assessment, the plaque was disclosed using 1% erythrosine solution.
Following the initial plaque scoring, the subjects were given a new manual toothbrush and were asked to brush their teeth in their usual technique with or without a dentifrice as per randomization. Following brushing, the subjects rinsed their mouth and the remaining postbrushing plaque was assessed in the same manner as mentioned earlier. Difference in plaque score before commencement of tooth brushing and after, constituted the plaque reduction. After the first session, the subjects were sent back to continue their usual natural oral hygiene regimen for one week (Washout). After one week, they abstained from oral hygiene for 48 hours and returned for the second session of plaque disclosure. They were assigned to either with or without dentifrice group, different from their first session. Prebrushing and postbrushing scores were assessed and recorded (PH).
Before starting, the subjects were asked to wet the brush head with normal water and the brushing time was supervised for a duration of two minutes for the whole mouth, , 30 seconds per quadrant ,15 seconds for the buccal side, and 15 seconds for the lingual side. When dentifrice was used for brushing, 2 ml of dentifrice was dispensed onto the toothbrush using a syringe loaded with dentifrice (KR). The supervision of the brushing procedure was done by a different examiner (HA). A stop watch was used and a signal was given to the subject to change the brushing surface. This procedure of randomization and allotment to either of the groups was done by a different examiner (HA).
Since the disclosing solution stains red, there was every chance that the subject could get influenced by the red color and concentrate on those areas when observing in the mirror, during brushing. To avoid such a bias, the mirror was covered with a red foil, so that the red areas were not conspicuous and merged with the surroundings. This was as per observations in a previous study. 
Mean, full-mouth plaque indices were calculated for each subject at each session [pre- and postbrushing] and the difference between prebrushing and post-brushing scores was expressed as a percentage of plaque reduction [100 ΄ Pre-brush - Post-brush/Pre-brush]. The mean values of the percentage plaque reduction were calculated and an independent t-test was used for statistical analysis. Statistical significance was established at P≤0.05.
To explore the reason for the observed difference in plaque removal, plaque indices were further estimated for different tooth surfaces (buccal, lingual, approximal) and converted to percentage plaque reduction, using the formula mentioned earlier. Parametric tests (Paired t test) were used to test the differences of plaque reduction between the brushing procedures for these surfaces. P values ≤ 0.05 were considered statistically significant.
| Results|| |
Out of 52 students recruited, four students did not participate, six students dropped out after the first phase, either due to their academic work schedule  or because of their health conditions.  The remaining 42 students were divided into two groups (A and B) of 21 each and used dentifrice in the first or second session as per randomization.
The mean of the total plaque indices pre- and postbrushing with and without dentifrice are tabulated in [Table 1]. Brushing with a dentifrice resulted in a mean plaque reduction of 57.35% and brushing without a dentifrice resulted in a mean plaque reduction of 66.19% [Table 2]. This 9% difference is statistically significant (P≤0.001).
The explorative analysis for different surfaces and the total percentage plaque reduction on mid-surfaces and approximal surfaces is shown in [Table 3].
| Discussion|| |
Tooth brushing remains the mainstay of oral health measures universally. The toothbrush alone has long been considered the primary tool in overall plaque control.  The dentifrice has been primarily viewed as a delivery vehicle for fluoride, tartar, and breath control components.  There are conflicting opinions about the efficacy and role of toothpaste in plaque removal.
Toothpaste appears to provide little or no additional physical plaque removal potential to the toothbrush, although some chemical plaque inhibition is conferred, probably by the detergents contained within the toothpaste.  However, there are also reports about the harmful effects of detergents and abrasives contained in the toothpaste resulting in abrasion, by the dissolution of the collagen matrix.  The problems of taking an overdose of fluorides in toothpastes and the possible, but rare, chances of allergic reactions should also be borne in mind.
Volpenhein et al., compared the plaque removal effectiveness of tooth brushing with water alone versus tooth brushing with a dentifrice, and showed greater plaque reduction with dentifrice than with water. Comparing the usage of a dentifrice and water, Harrap reported no significant difference in gingival index scores over a four-week period.  Owing to the equivocal ideas on the efficacy of toothpastes during brushing, the present study was designed to unravel the role of toothpaste during manual tooth brushing.
The present study is a 2 Χ 2 crossover double-blinded design, which is conducted to distinguish the role of toothpaste alone in plaque reduction during manual tooth brushing. Other studies , reported using toothpaste slurry to establish the anti plaque properties of toothpaste alone in comparison with conventional tooth brushing. However, such trials with slurry are not of practical value as toothpaste is not normally used as a slurry, instead it is used along with a toothbrush. The present crossover design in two sessions of tooth brushing, with and without dentifrice, is more rationale and objective and applicable as an oral hygiene trial.
By using a crossover design, there is no carryover effect, usually observed in a split mouth design. To rule out any carryover effect even remotely, a washout period of one week was given between two sessions.  Also, the subjects themselves acted as their own controls, thereby controlling patient-related factors of brushing (brushing manner, force, and dexterity). Moreover, the crossover design when compared with a parallel design, greatly increases the power to detect differences, if any. 
All the subjects were provided with the same type of toothbrush in both the sessions, so that there was no variation in bristle design, stiffness, and other brush-related factors.  A familiarization period of two weeks was provided so that the subjects got accustomed to the design of the toothbrush and also to the taste of the dentifrice under test. An attempt was made to have the brushing performed in as near a routine fashion as possible, being unsupervised and only standardized to time. As the subjects acted as their own controls, differences in brushing efficacy between subjects was not a confounding factor. The dentifrice used was a normal and routinely used type, not containing any special or active anti-plaque, antibacterial agents, whose effect on mechanical plaque control if present might have influenced the final outcome.
Paraskevas et al., reported, 3% more plaque reduction when brushing without dentifrice compared to brushing with dentifrices with different relative dentine abrasivity.  The same group in 2007 had reported a 6% greater plaque reduction when no dentifrice was used and tooth brushing was the sole oral hygiene regimen.  The greater plaque reduction obtained without dentifrice when compared to brushing with dentifrice was attributed to ineffective plaque removal on the proximal surface due to a sliding effect of the dentifrice. This effect could have prevented the toothbrush bristles from reaching the proximal surfaces. 
In the present study, brushing with a dentifrice resulted in a mean plaque reduction of 57.35% and 66.19% without dentifrice. This 9% difference in plaque reduction is considered to be statistically significant (P≤0.001). When compared to the buccal and lingual surfaces, plaque removal was less on the approximal surfaces either with or without dentifrice. This is not surprising as it is well-appreciated that a toothbrush alone is capable of removing up to 1 mm of subgingival plaque, but is ineffective in the inter-proximal region.  The difference in mean plaque reduction on the mid-surfaces with dentifrice and without dentifrice is 7.5% and on the approximal surfaces, this difference is 5.3%. Although these differences are not statistically significant, a trend is observed toward increased plaque reduction without dentifrice on both surfaces. The sliding effect that was suggested by Paraskevas,  negating the effect of the toothbrush on approximal surfaces, if related to these results, seems to be operating on the mid-surfaces also along with the approximal surfaces. Because of this effect, the bristles of the brush slide over without proper contact with the tooth surface in the presence of a dentifrice, and hence, results in ineffective plaque removal. Another possible explanation could be, the subjects recruited are healthy student volunteers with well-maintained oral hygiene practices, whereas, in the previous quoted study,  the subjects recruited belonged to a general population. As the level of motivation and education in subjects of the present study is better with regard to brushing practices, their brushing may be closer to ideal tooth brushing, concentrating equally on mid-surfaces as well as, approximal surfaces.
During manual brushing, the mechanical action of the bristles of the toothbrush disrupts the organization of the plaque,  but the precise role of dentifrice in plaque removal has been debatable. While a considerable volume of literature attributes several beneficial properties and endorses it, a small body of researchers questions its efficacy. Both the groups have used standard protocols, although the methodology has been variable. Usage of toothpaste has become a daily ritual and the most common oral hygiene method in most of the developed and the developing world. However, lingering doubts are expressed about the plaque removal efficacy of toothpastes, and such studies are published in dental journals of repute. The fact that toothpaste use does not enhance plaque removal when used in conjunction with a toothbrush and instead may lessen the brushing effect, should slow down the tempo of its widespread usage.
| Conclusion|| |
Toothbrushes and the accompanying toothpastes occupy the major slice of the pie when it comes to public money spent on oral hygiene products.  People buy toothpaste not only to clean the teeth, but also for its content of an anti-caries action, desensitizing effects, for the feeling of freshness, and to reduce malodor. To such an extent toothpaste usage may be recommended.
Toothpaste is an institution by itself; it is in the ethos of modern living style. To deride or discourage its use by a few sporadic trials would be a feeble attempt at demystifying this behemoth of an object. There is a need for larger clinical trials, with different population samples, to precisely delineate the role of toothpaste in oral hygiene practice.
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Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh
[Table 1], [Table 2], [Table 3]
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