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Table of Contents   
ORIGINAL RESEARCH  
Year : 2020  |  Volume : 31  |  Issue : 5  |  Page : 743-751
Comparative evaluation of tooth surface roughness caused by three different powered toothbrushes and a novel manual toothbrush –An SEM and AFM study


1 Department of Periodontology, Jawaharlal Nehru Institute of Medical Sciences Dental College, Imphal, Manipur, India
2 Department of Periodontology, RVS Dental College and Hospital, Coimbatore, India
3 Department of Periodontology, Indira Gandhi Government Dental College, Jammu, India
4 Department of Periodontolgy, Teerthankar Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India

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Date of Submission01-Mar-2018
Date of Decision12-Jul-2018
Date of Acceptance28-May-2019
Date of Web Publication08-Jan-2021
 

   Abstract 


Background: Toothbrush is the most frequently used tool for mechanical plaque control. Variety of manual and powered toothbrushes are available in the market, and it is often a dilemma for a common man that which one to choose among the wide range. Thus, the purpose of the present study was to evaluate and compare the tooth surface roughness caused by three different powered toothbrushes. Method: In total, 160 samples comprising of 80 enamel and cementum each were equally and randomly divided into four groups: Group 1 multi-directional powered toothbrushing; Group 2 oscillating/rotating/pulsating powered tooth brushing; Group 3 sonic powered tooth brushing; and Group 4 manual tooth brushing. They were further sub-divided equally into Control and Test. The Test samples were brushed for 2 min every day for a period of 1 month. The prepared samples were evaluated for surface roughness using scanning electron microscope at 1000 × magnification and atomic force microscope at the nanoscale. Result: A statistically significant difference was seen in the enamel and cementum roughness between multi-directional tooth brush group and sonic (P = 0.00); multi-directional tooth brush group and manual tooth brush group (P = 0.00); oscillating tooth brush group and sonic group (P = 0.00); oscillating tooth brush group and manual tooth brush group (P = 0.00); and sonic group and manual tooth brush group (P = 0.00). Conclusion: The surface microroughness caused by tooth brushing was found to be least using multi-directional and oscillating/rotational/pulsating powered toothbrush, followed by sonic powered toothbrush and maximum in manual toothbrush.

Keywords: Atomic force microscopy, manual toothbrush, powered toothbrushes, scanning electron microscopy, surface scratches, surface roughness

How to cite this article:
Loitongbam M, Mohan R, Chowdhary Z, Mehrotra S. Comparative evaluation of tooth surface roughness caused by three different powered toothbrushes and a novel manual toothbrush –An SEM and AFM study. Indian J Dent Res 2020;31:743-51

How to cite this URL:
Loitongbam M, Mohan R, Chowdhary Z, Mehrotra S. Comparative evaluation of tooth surface roughness caused by three different powered toothbrushes and a novel manual toothbrush –An SEM and AFM study. Indian J Dent Res [serial online] 2020 [cited 2021 Jan 18];31:743-51. Available from: https://www.ijdr.in/text.asp?2020/31/5/743/306442



   Introduction Top


Dental plaque is the primary causal factor in both gingivitis and periodontitis. Good oral hygiene by effective tooth brushing has a key role in maintaining oral health preventing periodontal disease and dental caries. Daily use of a toothbrush and other oral hygiene aids is the most dependable way of achieving oral health benefit for all individuals. Plaque occurs within hours of brushing and must be completely removed to prevent inflammation of the gingiva. Effective toothbrushing depends on a number of factors including motivation, knowledge, manual dexterity of the individual, and a type of tooth brush.[1]

Although the first toothbrush is thought to have been used in about 1000 A.D, later in 1600 the bristle tooth brush appeared in China and was first patented in America in 1857.[2] With the introduction of the powered toothbrushes in 1930s, an alternative to manual methods of toothbrushing was established. Currently, powered tooth brushes have oscillating and rotating motions and some brushes use low-frequency acoustic energy to enhance cleaning ability.[3]

The introduction of the powered toothbrush has led to a large number of studies comparing the safety and efficacy of powered toothbrushes to manual toothbrushes.[4] Studies have shown that one design is better over another in terms of plaque removal, but the real test is whether this difference results in a better periodontal health or not.[5],[6],[7] They are widely considered safe and highly effective, with a large meta-analysis published by the independent Cochrane collaboration.[8] Powered toothbrushes have evolved and grown technologically more sophisticated in recent years with increased acceptance by consumers. The new generation powered toothbrushes also incorporate features, such as aimed at improving the efficacy of cleaning and reducing the likelihood of toothbrush abrasion and gingival trauma in the long term.

Studies have shown varying results regarding the efficacy of powered toothbrushes for the removal of plaque.[7],[9] It is widely believed that use of a powered toothbrush reduces brushing force and the incidence of gingival bleeding. Cochrane study demonstrates that powered toothbrushes with an oscillating, rotating mechanism are more effective than manual toothbrushes and other power toothbrushes, including those with sonic mechanism, for removing plaque and reducing gingivitis. Similarly, in-vitro as well as clinical studies has shown that electric toothbrushes are superior to manual brushes in terms of removing plaque and improving gingival health.[10],[11],[12],[13],[14],[15] However, other studies conclude that conventional and electric brushes are equally effective.[16]

A large number of studies have been conducted to evaluate the efficiency of toothbrushes both powered and manual for removal of plaque with limited literature available on surface roughness created by various toothbrushes, as the surface roughness has great importance in plaque formation after brushing enamel or cementum from the exposure of root or gingival recession areas. Hence, the present study was hypothesized on the criteria that which toothbrush is better in terms of producing less surface roughness on the tooth surface microtopography and was conducted to evaluate and compare the tooth surface microroughness caused by 3 different commercially available powered toothbrushes i.e. a multi-directional, oscillating/rotational/pulsating and sonic toothbrush and comparing with a manual toothbrush such as Pro-Health Clinical Pro-Flex by micro analysis using atomic forces microscopy (AFM) and scanning electron microscopy (SEM).


   Materials and Method Top


A total of 80 periodontally compromised human teeth, from both male and female with age ranging from 35–65 years were extracted, collected, and sectioned to obtain 80 enamel and cementum samples each. Teeth with prosthesis, fracture, showing signs of external resorption, caries, abrasion, and erosion were not included in the study.

Study design

An in vitro study was conducted to evaluate and compare the surface roughness of the enamel and cementum subjected to tooth brushing by four different toothbrushes such as; Multi-directional powered toothbrush – Trizone 1000 (Oral B, USA), oscillating/rotational/pulsating powered toothbrush – Oxyjet + 3000 (Oral B, USA), Sonic powered toothbrush – Sonicare-Essence 5500 (Philips, USA), and a Manual toothbrush – Pro-health clinical Pro-Flex (Oral B, USA); as shown in [Figure 1].
Figure 1: Four different toothbrushes. (a) Multi-directional powered toothbrush – Trizone 1000 (Oral B, USA); (b) Oscillating/rotational/pulsating powered toothbrush – Oxyjet + 3000 (Oral B, USA); (c) Sonic powered toothbrush – Sonicare-Essence 5500 (Philips, USA); and (d) Manual toothbrush – Pro-Health clinical Pro-Flex (Oral B, USA)

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The extracted teeth were collected and stored at room temperature in 10% formalin. They were cleaned thoroughly to remove debris, tissue tags, and calculus from the tooth surface and were stored in isotonic sodium chloride at room temperature.

The study was conducted in accordance with the Helsinki declaration[17] approved by the Institutional ethics committee (TMU/EC/301). Informed consent from the patient was also obtained.

The teeth collected were randomly categorized into 4 groups, having 20 teeth each. They were further equally divided into sub-groups of enamel and cementum, having 10 teeth each. All the samples were sectioned into two equal longitudinal halves mesiodistally, using low speed (2500–3000 rpm) water-cooled diamond disc attached to contra-angle handpiece, with one half serving as Control group and the other as Test.[18] The Control samples were not subjected to any brushing procedure, whereas test samples were brushed with 4 different toothbrushes, as per the distribution. After preparation, Test group samples were brushed with a dentifrice (Oral B all rounder, USA) for 2 min/day, for a period of 1 month. After the brushing was performed, samples were thoroughly washed with distilled water and were stored in normal saline filled containers. They were equally distributed into 4 groups as follows:

  • Group 1 (Multi-directional powered toothbrush): Ten Test samples each of enamel and cementum were brushed for 2 min with Trizone 1000 powered toothbrush and dentifrice, as per manufacturer designed tooth brushing motion.
  • Group 2 (oscillating/rotating/pulsating powered toothbrush): Ten Test samples each of enamel and cementum were brushed for 2 min with Oxyjet + 3000 powered toothbrush and dentifrice, as per the manufacturer's designed tooth brushing motion.
  • Group 3 (Sonic powered toothbrush): Ten Test samples each of enamel and cementum were brushed for 2 min for one month with Sonicare- Essence 5500 powered toothbrush and dentifrice, as per the guidelines of a manufacturer.
  • Group 4 (Manual toothbrush): Ten Test samples each of enamel and cementum were brushed for 2 min with Pro-health clinical Pro-flex manual toothbrush and dentifrice, in a circular tooth brushing motion for the same period.


The brushing procedure of the sample was performed by one operator (M.L.), and the samples were analyzed with SEM (Carl Zeiss EV040 USA) and AFM (Park System XE70 USA) by a trained SEM and AFM interpreter of photomicrographs at Advanced Instrumentation Research Facility (AIRF) of Jawaharlal Nehru University, New Delhi, India.

Scanning electron microscopy- Sample preparation

The samples were mounted on metal stubs and dried in a silica gel vacuum desiccator. They were sputter coated with gold and examined under SEM. The micrographs of cementum and enamel surfaces were obtained at 1000 × magnification, at 20.0 KV voltage, 25 mA current and with eucentric sample stage.[18]

The photomicrographs were assessed by another blinded operator (S.M.) on the basis of the number of scratches present on the surface using the ARG SEM surface scoring system,[19] as described in [Figure 2].
Figure 2: ARG SEM evaluation system. It employs the principle of visual analog scale and is depending on Likert scale. The SEM photomicrograph is divided into 9 segments by drawing a grid as depicted in the figure above. The scoring system employs three observers to score and rate each grid segment according to their visual perception. The final score is accorded as an average of score of all the 9 grids i.e. Final score = (A1 + A2 + A3 + A4 + A5 + A6 + A7 + A8 + A9)/9

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Atomic force microscopy- Sample preparation

The samples were mounted on metal stubs and dried. The images of surface roughness at the nanoscale were obtained by AFM explorer using contact mode with tips from fibers silicon nitride. The image surface area was 5–100 μm, with a resolution of 300 points per row. The maximum measurable changes of the profile were measured and images with 20 μm × 20 μm within the center of the sample were obtained.[20]

Statistical evaluation

The data obtained were tabulated and statistically analyzed using SPSS version 22.0 statistical analysis software (IBM, Chicago, IL, USA).The continuous measurements were presented as Mean ± SD, and the tests applied were the one-way ANOVA test, Tukey HSD post hoc test, and paired t test. One-way ANOVA test was used to compare the enamel and cementum surface roughness in the multi-directional, oscillating, sonic, and manual toothbrush groups; whereas Tukey HSD post hoc test was used to compare the individual groups, and paired t test was used to compare the mean enamel and cementum surface roughness in the Test and Control groups. The significance was assessed at 5% level of significance at 95% confident interval, and the P value < 0.05, considered significant; <0.001, considered highly significant; and >0.05, considered as not significant.


   Result Top


An in vitro study was conducted to evaluate and compare the surface roughness of enamel and cementum using a multi-directional powered, oscillating/rotating/pulsating powered, sonic powered, and a manual toothbrush by SEM and AFM microanalysis.

The SEM photographs obtained at 1000 × magnification, demonstrated changes in the surface roughness of both enamel and cementum, for group 1, 2, 3, and 4 as shown in [Figure 3], [Figure 4], [Figure 5], [Figure 6], respectively.
Figure 3: SEM photomicrograph at magnification 1000 × of multi-directional powered toothbrush (Group 1), showing negligible scratches. (a) and (b) Shows enamel surface pre-brushing (control) and post-brushing (test); (c) and (d) Shows cementum surface pre-brushing (control) and post-brushing (test), respectively

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Figure 4: SEM photomicrograph at magnification 1000 × of oscillating/rotating/pulsating powered toothbrush (Group 2), showing minimal number of scratches. (a) and (b) Shows enamel surface pre-brushing (control) and post-brushing (test); (c) and (d) Shows cementum surface pre-brushing (control) and post-brushing (test), respectively

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Figure 5: SEM photomicrograph at magnification 1000 × of sonic powered toothbrush (Group 3), showing moderate increase in number of scratches. (a) and (b) Shows enamel surface pre-brushing (control) and post-brushing (test); (c) and (d) Shows cementum surface pre-brushing (control) and post-brushing (test), respectively

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Figure 6: SEM photomicrograph at magnification 1000 × of manual toothbrush (Group 4), showing extensively number of scratches. (a) and (b) Shows enamel surface pre-brushing (control) and post-brushing (test); (c) and (d) Shows cementum surface pre-brushing (control) and post-brushing (test), respectively

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The one-way ANOVA test was used for enamel and cementum surface for all groups as shown in the [Table 1]. In the Control samples of enamel, the surface roughness was highest in sonic toothbrush group (10.50 ± 4.06) followed by oscillating group (9.90 ± 3.47) and manual tooth brush group (9.70 ± 4.05), demonstrating that the multi-directional tooth brush group showed least surface roughness (8.60 ± 3.62). In the Control samples of cementum, the surface roughness was almost equal in multi-directional (9.00 ± 3.88) in manual tooth brush group (9.00 ± 2.70) followed by oscillating (8.60 ± 2.45) and sonic (7.60 ± 3.95). However, no statistically significant difference was found in both enamel and cementum surface roughness (P = 0.73; P = 0.75).
Table 1: Comparison of enamel and cementum surface roughness in multi-directional powered toothbrush (Group-1), oscillating/rotating/pulsating powered toothbrush (Group-2), sonic powered toothbrush (Group-3), and manual toothbrush (Group-4) in control and test groups

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[Table 1] also shows that in the test samples of enamel, the surface roughness was highest in manual toothbrush group (26.50 ± 8.77) followed by sonic group (25.60 ± 6.25) and oscillating tooth brush group (15.80±0.08), demonstrating that the multi-directional tooth brush group showed least surface roughness (12.60 ± 4.52). Similar pattern was also noticed in the test samples of cementum, where the surface roughness was highest in manual tooth brush group (33.50 ± 4.88) followed by sonic tooth brush group (17.20 ± 5.37) and oscillating (14.80 ± 2.78). The least was seen in the multi-directional tooth brush group (13.30 ± 4.34). A statistically significant difference was found in both enamel and cementum surface roughness. (P = 0.00; P = 0.00)

In [Table 2], post-hoc Tukey HSD test for each group is compared with the other groups. A statistically significant difference was seen in the enamel roughness between multi-directional tooth brush group and sonic (P = 0.00); multi-directional tooth brush group and manual tooth brush group (P = 0.00); oscillating tooth brush group and sonic group (P = 0.00); oscillating tooth brush group and manual tooth brush group (P = 0.00); and sonic group and manual tooth brush group (P = 0.00). Similarly, when the cementum surface roughness was measured, a statistically significant difference was seen between multi-directional tooth brush group and manual tooth brush group (P = 0.00); oscillating tooth brush group and manual tooth brush group (P = 0.00); and sonic group and manual tooth brush group (P = 0.00).
Table 2: Post hoc tests showing comparison between the groups for enamel and cementum surface roughness

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In [Table 3], paired t test was used for the comparison of the enamel and cementum surface roughness between the Test and Control group using different toothbrushes. It was seen that the enamel and cementum surface roughness was higher in the Test group as compared to the Control group, and this difference was statistically significant (P = 0.00).
Table 3: Comparison of enamel and cementum surface roughness in Multi-directional, Oscillating, Sonic, and Manual toothbrush

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In [Figure 7] (A and B), the enamel and cementum surface roughness comparisons between the four groups are illustrated in the form of bars. The overall results showed that brushing caused increased scratches/roughness on cementum as compared to enamel in all the four groups.
Figure 7: Intergroup surface roughness comparison (a) Enamel surface roughness between groups and (b) Cementum surface roughness between groups

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The results of the photomicrographs evaluated through ARG SEM surface evaluation scoring system were confirmed by the AFM images obtained at 20 μm × 20 μm magnification. The AFM images for Group 1 i.e. Multi-directional powered toothbrush showed least number of scratches/surface roughness as shown in [Figure 8]; whereas AFM images for Group 4 i.e. Manual toothbrush showed the maximum number of scratches/surface roughness, shown in [Figure 9].
Figure 8: AFM images at 20 μm × 20 μm magnification showing the least number of scratches in (Group-1) multi-directional powered toothbrush. (a) Shows enamel surface and (b) Shows cementum surface

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Figure 9: AFM images at 20 μm × 20 μm magnification showing the maximum number of scratches in (Group-4) manual toothbrush. (a) Shows enamel surface and (b) Shows cementum surface

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The results of the present study demonstrated that toothbrushing using Multi-directional powered toothbrush is the most efficient causing least surface roughness, however, manual toothbrush produces a considerable amount of surface roughness on both enamel and cementum surfaces.


   Discussion Top


Plaque removal is an effective daily home care regimen, which is an important element of oral health. Control of plaque and debris is essential for the prevention of inflammatory periodontal diseases and dental caries. Plaque-induced gingivitis is one of the most common, yet preventable, disease worldwide.[8] The most common method of supragingival plaque control is the mechanical removal of plaque by toothbrushing. Manual toothbrushes have been the most commonly used mode of oral hygiene, since its discovery. To improve the efficiency of tooth brush and its adaptability, various changes in the design and size along with bristle types have taken place over the years. Today, various types of manual and powered toothbrushes are available over-the-counter.

Studies by Khambay BS and Walmsley AD in 1995, McCracken GI et al. in 2004 and Dentino AR et al. in 1999 have shown that powered toothbrushes are more effective in the removal of plaque as compared to a manual toothbrush.[12],[14],[15],[21],[22],[23] However, in contrast, Heanue M et al. in 2003, his study suggested that only powered toothbrushes that worked with rotating/oscillating and those that moved in more than one direction are better than a manual toothbrush.[12],[13],[24]

Dentifrices have been used in conjunction with toothbrush since a long time, and brushing with a dentifrice is an example of a triple body abrasion process.[25],[26] Studies have shown that brushing without dentifrice is apparently incapable of abrading enamel and dentin, whereas others show that toothbrushing without dentifrices may include abrasion.[25],[26] However, evidence supports the fact that toothpaste abrasiveness may be caused by a combination of its erosive effect and mechanical effect of the toothbrush bristles.[26] As there is no variation in the type of dentifrice used in the present study, it was not possible to relate abrasion and its severity.

In the present study, three different commercially available powered toothbrushes (multi-directional, oscillating/rotating/pulsating, and sonic) working on different principles are compared with a novel manual toothbrush. The multi-directional powered tooth brush has three distinct brush zones, which collectively contain over 2,000 bristles, multi-directional movements are delivered by 8,800 direction changes per min, also provides 40,000 pulsations. The oscillating/rotating/pulsating technology power toothbrush work on oscillating/rotating principle combining 20,000 pulsations and has a small round head giving 7,600 strokes per min. The sonic is defined as having a frequency within the audibility range of the human ear, which established 20 Hz to 20 kHz, giving 31,000 strokes per min with a scrubbing motion. There are studies conducted, by Dentino A et al. in 1999, Klukowska M et al. in 2012, Biesbrock AR et al. in 2007, and Nathoo S et al. in 2014; on powered toothbrushes to evaluate their superiority and plaque removal efficiency compared with the manual toothbrush or with each other with varying results.[23],[27],[28],[29] Minimal attention was paid on the surface roughness caused on tooth surface owing to both manuals as well as powered brushes. Various documented studies analyzed only the plaque removal efficacy of the brushes used and not the surface roughness caused on enamel and cementum. The present study has evaluated and compared the effects of powered and a recently introduced and unique manual toothbrush on enamel and cementum surfaces by SEM at 1000 × magnification depending on the number of scratches produced on the enamel and cementum surfaces using ARG SEM[14] evaluation scoring system.

The novel manual toothbrush used in the present study had a modified design comprising of multi-tufted filaments, flat trimmed, and polished end bristles arranged criss-cross in two flexing side promising to reach most sites within the dental arch and also to clean even the most difficult areas. Kumar S et al., Drisko et al., and Bass found that flat trim end bristle design cause less surface abrasion compared to other designs.[25],[30],[31] The novel manual toothbrush was considered.

The surface roughness caused by various toothbrushes in the present study was evaluated by scratches and the evaluation within the intra-group revealed a statistically significant difference in the scratches produced by brushing on enamel as compared to cementum surface, with higher scratches on the cementum for each group. This can be attributed to higher density and resistance of enamel to physical trauma than the cementum.[14]

The present study indicates that manual toothbrushes cause maximum surface scratches as compared to powered toothbrushes. This can be explained as effects of varying pressure generated during manual brushing owing to self performing strokes. The incidence of increased scratches/roughness by manual toothbrush may also be attributed to the use of the soft bristle toothbrush with the toothpaste. Studies have proved that the use of a soft bristle brush with toothpaste is more abrasive than hard bristle brush used with toothpaste.[32],[33] This could be explained as; the soft toothbrushes have bristles with more flexibility and have more contact with tooth surface.[12],[34] They also retain more toothpaste, which is likely to cause more abrasion.[34]

The sonic powered toothbrush has shown less enamel and cementum surface roughness compared to manual toothbrush probably because of limited pressure exerted by bristle movement of the powered toothbrush compared to heavy pressure by manual brushing. The results are in accordance with Natho et al. and Starke M et al.[29],[35] It also demonstrated increased surface roughness for enamel and cementum compared to oscillating and multi-directional powered toothbrushes, respectively. This may be owing to an increased number of vibrations at 20 Hz to 20 kHz rpm in comparison to oscillating/rotating/pulsating and multi-directional toothbrush.

Brushing by manual and sonic toothbrushes caused significant surface roughness on both enamel and cementum. Oscillating/rotating/pulsating and multi-directional powered toothbrushes caused minimal scratches.

The multi-directional powered (TRIZONE) toothbrush research shows that it outperformed manual and sonic controls in reducing plaque and gingivitis even in the hard-to-reach interdental spaces and marginal areas. Dental professionals should consider this novel multi-directional power brush for patients who need improved plaque control and gingival health.[11],[36],[37],[38],[39],[40],[41]

Furthermore, AFM analysis at 20 μm × 20 μm at the nanoscale both for Control and Test groups revealed that manual toothbrush caused maximum number of scratches as compared to the other Test groups. In the present study, significant surface roughness caused by various powered toothbrushes and manual toothbrush was analyzed, and the overall results suggested that the use of powered toothbrushes over manual is more efficient, as the former are pressure sensitive and are likely to cause less surface damage.

Limitations and recommendations

The present study had certain limitations such as the effect of saliva and its role in the prevention of surface roughness/abrasion and the abrasive nature of the toothpaste. Therefore, further longitudinal studies and clinical trials are needed to see the tooth brush and toothpaste abrasion and gingival trauma, along with the relationship of different brushes and soft/ hard tissue abrasion/roughness.


   Conclusion Top


Regular brushing over the years can lead to significant loss of tooth structure. Surface roughness produced by brushing may vary with the brushing techniques, forces/pressure exerted, and the degree of abrasion caused by use of dentifrices. On the basis of the microanalysis by SEM and AFM in the present study, multi-directional and oscillating/rotating/pulsating powered toothbrushes proved to be superior in terms of causing less tooth surface roughness and removing plaque when compared to sonic powered toothbrush and a manual toothbrush.

Powered toothbrushes may be recommended for regular use in general and specifically oscillating/rotating/pulsating and multi-directional powered toothbrushes while selecting the powered toothbrush, as they are more efficient in plaque removal causing minimum roughness to the enamel and cementum.

Acknowledgments

The authors wish to thank especially Dr. Akansha Sharma, In-charge SEM laboratory at AIRF, Jawaharlal Nehru University- New Delhi (India), for her support as well as technical guidance and assistance throughout the study.

Financial support and sponsorship

Self-funded.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Zoya Chowdhary
Department of Periodontology, Indira Gandhi Government Dental College, Jammu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_163_18

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