Accepted Manuscript

The Effect of the Bass Intrasulcular Tooth Brushing Technique on the Reduction of
Gingival Inflammation: A Randomized Clinical Trial.

Federico Ausenda, Natalie Jeong, Peter Arsenault, Robert Gyurko, Matthew

Finkelman, Irina F. Dragan, Paul A. Levi, Jr.

PII: S1532-3382(18)30305-1
DOI: https://doi.org/10.1016/j.jebdp.2019.01.004
Reference: YMED 1308

To appear in: The Journal of Evidence-Based Dental Practice

Received Date: 23 October 2018

Revised Date: 12 January 2019
Accepted Date: 16 January 2019

Please cite this article as: Ausenda F, Jeong N, Arsenault P, Gyurko R, Finkelman M, Dragan IF, Levi
Jr PA, The Effect of the Bass Intrasulcular Tooth Brushing Technique on the Reduction of Gingival
Inflammation: A Randomized Clinical Trial., The Journal of Evidence-Based Dental Practice (2019), doi:
https://doi.org/10.1016/j.jebdp.2019.01.004.

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 ACCEPTED MANUSCRIPT

Title

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The Effect of the Bass Intrasulcular Tooth Brushing Tech-

nique on the Reduction of Gingival Inflammation: A Ran-

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domized Clinical Trial.

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Federico Ausenda, Department of Periodontology at Tufts University School of Dental Medicine, 1 Kneeland st, Boston, MA,
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USA, 02111. federico.ausenda@gmail.com
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Natalie Jeong, Department of Periodontology at Tufts University School of Dental Medicine, 1 Kneeland st, Boston, MA, USA,

02111.
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Peter Arsenault, Department of Comprehensive Care at Tufts University School of Dental Medicine, 1 Kneeland st, Boston, MA,
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USA, 02111.
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Robert Gyurko, Department of Periodontology at Tufts University School of Dental Medicine, 1 Kneeland st, Boston, MA, USA,

02111.
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Matthew Finkelman, Division of Biostatistics and Experimental Design at Tufts University School of Dental Medicine, 1
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Kneeland st, Boston, MA, USA, 02111.

Irina F. Dragan, Department of Periodontology at Tufts University School of Dental Medicine, 1 Kneeland st, Boston, MA, USA,

02111.
 ACCEPTED MANUSCRIPT

Paul A. Levi Jr, Department of Periodontology at Tufts University School of Dental Medicine, 1 Kneeland st, Boston, MA, USA,

02111.

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Abstract Objectives: The primary objective of this randomized controlled

clinical trial was to investigate the effect of the Bass Intrasulcular Technique

(BIT) on reducing gingival inflammation at 4 and 12 weeks compared with the

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tooth brushing techniques commonly used. Methods and Materials: After re-

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ceiving ethical approval from the Tufts Health Sciences Institutional Review

Board, 55 subjects were invited to participate in the study. Only the subjects

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who presented with bleeding on probing (BoP) were enrolled. The test group

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(BT) was instructed in how to use the BIT and the control group (NI) received
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no brushing technique instructions. Clinical measurements (probing depth,
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plaque score, BoP) of each tooth were recorded at 4 and 12 weeks. The tooth-

brushes of all participants were photographed and assessed by two blinded

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examiners using ImageJ software. The statistical significance between the co-
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horts’ BoP and their plaque score results was assessed via hierarchical logistic
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regression. The analyses were performed with SAS software (version 9.4; SAS

Institute, Cary, NC). Results: Forty-eight participants were eligible to partici-

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pate and were randomly assigned to one of two groups (N=24). The BT group
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showed significantly smaller percentages of BoP than the NI at 4(BT=12.4%

and NI=31.4%) and 12 (BT=11.6% and NI=43.8%) weeks. The difference in

plaque scores at 12 weeks was statistically significant (p=0.0003) between the

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two groups. At 12 weeks, the Mann-Whitney U Test indicated that the differ-

ence between the groups in terms of toothbrush area was statistically signifi-

cant (p=0.043). Conclusions: Within the limitations of this randomized con-

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trolled clinical trial, the participants brushing with the BT were significantly

more effective in reducing gingival inflammation as determined by BoP com-

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pared with participants who had no instructions on brushing techniques: at

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12 weeks there was less toothbrush deformation with the BT group compared

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with the control group. Clinical Relevance: The BT should be recommended
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particularly to patients exhibiting BoP and periodontal diseases.
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Key Words
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Tooth brushing technique, Bass technique, toothbrush wear, gingival inflam-

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mation.
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Introduction

Accumulation of bacterial biofilm increases the probability of caries, periodontal

and peri-implant diseases.1,2 These inflammatory conditions have been shown to

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negatively affect systemic health.3 Effective use of the toothbrush is fundamental

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to prevent the occurrence of these diseases. Over the years, there have been various

tooth brushing techniques recommended; however, to the authors’ knowledge there

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is limited evidence reporting on the use of bleeding on probing (BoP) as the crite-

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rion for measuring effectiveness. The Stillman, the Charter and the Fones tech-
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niques were proposed in the early 1900s, whereas the Bass Intrasulcular Tech-

nique (BIT) and the Modified BT (MBT) were described in the mid to late 1900s.
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C.C. Bass was the first to emphasize the insertion of the toothbrush bristle tips into
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the gingival crevice, using a short (3-5 mm) back- and -forth motion.4,5 The BT and
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the MBT are sulcular techniques, whereas the Stillman, Charter, and Fones meth-
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ods use a sweep or scrub technique. Most commonly, when using a toothbrush, in-

dividuals scrub the occlusal, facial and lingual surfaces of the teeth for less than
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120 seconds twice a day.6 There are conflicting reports in the literature regarding
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tooth-brushing techniques. Numerous authors7-9 prefer the BT method4 as effective

in plaque removal whereas others recommend the Fones. Thus, it is fundamental

for preventive dentistry to determine the most effective method of tooth brushing.
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BoP is evidence of a bacterial infection due to the presence of toxins from bacteria

elaborated subgingivally.10-12 Although supragingival plaque is important in the de-

velopment of caries, it is the subgingival flora that is critical in the development of

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gingivitis and periodontitis.10-12 If gingival inflammation is reduced or eliminated

with sulcular plaque removal, supragingival plaque must be removed in the pro-

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cess. The theory of plaque removal is displacement, not abrasion.13 Additionally,

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the efficacy of plaque removal may lie not only in the technique used, but also in

the deformation of the toothbrush bristles through use.

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The American Dental Association advocates brushing with a method similar to the
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MBT and supports replacing a toothbrush every 3-4 months.14 It is well document-
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ed that toothbrush bristles become permanently bent (deformed) over time.15-17

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However, there is no consensus on how many uses or which technique causes for a

toothbrush to become ineffective in removing plaque.18-27 Some authors15,20,21 have

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concluded that deformed bristles are as effective as new ones in plaque removal,
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whereas others16,17,22,23,28 have stated that there are differences. In these studies a
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variety of techniques were used. Some used a BT or an MBT;14,22,24 others instruct-

ed the participants to use short horizontal strokes;20 and there were some that did

not control for brushing technique.23,28 To date there is little evidence to discern the
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effectiveness of brushing techniques and toothbrush wear in reducing or preventing

gingival inflammation.29

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Objectives:

The primary aim of the study was to determine the effect of the BT (test group) on

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reducing gingival inflammation at 4 and 12 weeks compared with the tooth brush-

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ing techniques most commonly used by the NI (control group). The secondary aim

was to determine the amount of toothbrush bristle deformation at 4and 12 weeks

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for both groups, evaluated by macroscopic photographs.
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Hypotheses:
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We hypothesized that there would be a higher reduction in gingival inflammation

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for the BT (test group) compared with the most common tooth brushing techniques
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used by the NI (control group) at 4and 12 weeks. We additionally hypothesized

that a greater bristle deformation would increase the gingival inflammation com-
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pared with reduced bristle deformation at 4and 12 weeks.

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Material and Methods:

Study design

This study was a double armed randomized clinical trial conducted in the Depart-

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ment of Periodontology of the Tufts University School of Dental Medicine, Bos-

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ton, MA, USA, and consisted of two groups: BT (test) and NI (control). The sub-

jects were randomized in two groups and assigned to either BT or NI following a

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printout of a randomization scheme that was created using the statistical software

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package R (version 3.1.2) before the outset of the study. The study was approved
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by the Tufts Health Sciences Institutional Review Board and registered on Clini-

calTrials.gov #NCT03158350. Throughout the study the principles of the Declara-

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tion of Helsinki were followed and the Consolidated Standards of Reporting Trials
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(CONSORT) guidelines were applied.30

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Study participants

Respecting the approved protocol, subjects were invited to participate if they

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fulfilled the following inclusion criteria: 18 years of age; presence of a min-

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imum of 20 teeth; had a professional prophylaxis done within 3months prior

to the beginning of the study; exhibited BoP on examination > 20% in the

cervical areas; and cervical gingival probing depths (PD) between 1-3mm.

Subjects were not enrolled if they had fixed orthodontic appliances (includ-
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ing lingual retainers or clear incremental aligners), were smoking, received

antibiotic treatment 1month prior to or during the study, or self-reported

pregnancy.

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Study interventions

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The study consisted of one baseline examination and two follow-up evaluations. At

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the baseline examination, the investigators observed and recorded the subjects’ ha-

bitual brushing techniques. All subjects were instructed to brush their teeth twice a

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day for 2minutes each time and to use an amount of toothpaste covering the area of

non-colored bristles at the end of the toothbrush. All subjects in both groups were
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asked to use only their assigned toothbrush and toothpaste throughout the duration
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of the study. There were no restrictions regarding interproximal plaque removal.

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Using a periodontal probe (UNC 1-15 Hu-Friedy), the examiners recorded cervical

PD on the buccal and lingual surfaces of each tooth (excluding third molars). The
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subjects returned 4weeks (+/- 5 days) following their baseline examination, at

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which time their eligibility was reviewed. The subjects’ toothbrushes were photo-
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graphed, and the BoP and PD were recorded. The subjects were again asked to

demonstrate their tooth brushing techniques, which were observed and recorded.

For the subjects in the BT group, tooth brushing technique instructions were re-
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viewed. At the third visit, 12 weeks (+/- 5 days) following the baseline examina-

tion, all measurements and procedures done at the second visit were repeated.

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Study outcomes

• Bleeding on Probing

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A complete mouth BoP score was recorded. The presence of BoP and plaque was

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documented as a binary variable (present or absent) for two surfaces on each tooth

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(buccal and lingual/palatal). Interproximal bleeding and plaque accumulation were
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not recorded, because the toothbrush primarily removes plaque cervically. Bleed-

ing was assessed by sliding the probe horizontally with the tip at the most apical
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portion of the gingival crevice from line angle to line angle on the facial and the
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lingual of all teeth. After observing the areas for 20 seconds the examiner assessed
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BoP. Subjects were then asked to chew a Sunstar-Butler GUM® disclosing tablet

for 30 seconds, swish it throughout their mouth, expectorate, and rinse with water.
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The presence of plaque on the buccal and on the lingual tooth surface was recorded
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as a binary variable.
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• Tooth brush deformation

At baseline each toothbrush was photographed with a fixed macro lens camera

(Nikon D90) to visualize the tip ends of the bristles (axial view). The camera set-

tings were maintained, and each toothbrush was positioned in the same standard
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pre-formed toothbrush holder, which was covered by a disposable plastic shield to

ensure infection control. For the purposes of calibration and standardization of the

pictures, a 5.5 x 2 mm rectangle of aluminum foil was applied on each toothbrush

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when photographed (Figure 1).

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Sample size calculation

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A calculation was performed to determine the sample size required to obtain ade-

quate power for the primary aim of the study. The calculation assumed that the av-

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erage number of sites evaluated per subject would be 48 (two sites per tooth with

an average of 24 teeth per subject). It was assumed that the intracluster correlation
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coefficient would be equal to ρ=0.02 based on Killip et al.31 Finally, based on the
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results of Harnacke et al.,32 it was assumed that the percentage of BoP would be
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20% in the group without instructions. On the basis of these assumptions, 19 sub-

jects per group were found to yield an effective sample size of 470 sites (using the
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formula of Killip et al. to account for intracluster correlation within a subject). A

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calculation of power was then conducted using nQuery Advisor (Version 7.0). As-
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suming an odds ratio of 0.60, which was determined to be clinically significant, the

aforementioned sample size of 19 subjects per group was adequate to obtain a two-

sided hypothesis test with a Type I error rate of 5% and a power of 82%. To ac-
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count for approximately 20% attrition, a sample size of 24 subjects per group was

used.

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Blinding

At the initial examination the evaluators, P.L. and F.A., were calibrated and blind-

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ed as to which group the subject would be assigned. Blinded evaluators, J.H. and

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S.P., independently measured the toothbrush bristle area on the pictures using the

Image J software. The measurements were averaged and analyzed.

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Statistical methods
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The statistical analyses were performed with SAS software (version 9.4; SAS Insti-
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tute, Cary, NC). The percentage of sites with BoP and the percentage of sites with
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plaque at each time point were calculated by group. The experimental units were

defined as sites rather than patients because the patients had a varying number of
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teeth. The statistical significance between the cohorts’ BoP and their plaque score
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results was assessed via hierarchical logistic regression. The mean, median, inter-
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quartile ranges and standard deviation of the deformation measurements (areas)

were calculated at each time point for each group. Comparisons between the

groups’ deformation measurements were assessed via the Mann-Whitney U Test.

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The two groups were compared with regard to gender distribution via the chi

square test. P-values less than 0.05 were considered statistically significant.

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Results:

A total of 55 subjects were screened and 48 subjects started the study, with 24 par-

ticipants assigned to each group (Figure 2). The BT had a mean age of 29.36 and a

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standard deviation (SD) of 10.13, with a median of 26.00 and an interquartile range

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(IQR) of 4.25. The NI group had a mean age of 27.92 and an SD of 4.63, with a

median of 27.00 and an IQR of 4.00. The Mann-Whitney U test showed no signifi-

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cant difference between groups in regard to age (p=0.641). The two groups were

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compared in terms of gender distribution via the chi-square test and there was no
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statistically significant difference (p=0.253). In the BT group at baseline the “ha-

bitual brushing method” of 83.3% of subjects was a non-sulcular brushing tech-

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nique, and 87.5% of NI subjects were using a non-sulcular technique (Table 1). At
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the 12-week follow-up, a total of 45 subjects had completed the study; 24 belonged
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to the NI and 21 to the BT. (Figure 2) In the BT group three subjects were lost to
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follow up. One chose not to continue after 10 days, and the other two lost their

toothbrushes.
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Bleeding on Probing:

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At baseline the study population had a total of 2516 sites of which 27.5% showed

BoP. The BT group exhibited 26.8% BoP and the NI group showed 28.1% BoP

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with no significant difference (p=0.79). At 4 weeks the BT group had 12.4% of

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sites showing BoP, whereas the NI group had 31.4% of sites exhibiting BoP; the

difference was statistically significant (p<0.0001). At 12 weeks 11.6% of sites in

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the BT group exhibited BoP and 43.8% of sites in the NI group showed BoP; the

difference was statistically significant (p<0.0001). When adjusting for baseline

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BoP, the differences in BoP scores at 4and at 12 weeks were still statistically sig-
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nificant (p<0.0001) (Table 2).

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Toothbrush deformation:
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At baseline, in the BT group, the mean toothbrush area was 177.89 mm² (SD 6.73)
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with a median of 177.67 mm² and an IQR of 9.85. The mean area of the tooth-
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brushes in the NI group was 179.48 mm² (SD 8.66) with a median of 177.16 mm²

and an IQR of 12.0. The Mann-Whitney U Test indicated no significant difference

between the groups in terms of toothbrush area at baseline (p=0.482). At 4 weeks,

in the BT group, the mean toothbrush area was 184.41 mm² (SD 21.15) with a me-
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dian of 177.47 mm² and IQR of 7.37. The mean area of the toothbrushes in the NI

group was 193.17 mm² (SD 28.65) with a median of 185.83 mm² and an IQR of

38.99. The Mann-Whitney U Test indicated that there was no significant difference

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among the groups in terms of toothbrush area at four weeks (p=0.218). At 12

weeks, the mean toothbrush area for the BT group was 197.70 mm² (SD 40.83)

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with a median of 186.45 mm² and IQR of 22.02. The mean area of the toothbrushes

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in the NI group was 216.55 mm² (SD 42.22) with a median of 234.38 mm² and

IQR of 46.81. The Mann-Whitney U Test indicated that the difference among the

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groups in terms of toothbrush area was statistically significant (p=0.043).
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Ancillary analysis
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At baseline, the total population of subjects had 2516 surfaces, 47.5% of which ex-
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hibited plaque. The BT group had 43.6% of surfaces with plaque and the NI group

had 50.9%; the difference was not statistically significant (p=0.22). At 4weeks the
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BT group showed 27.2% of sites with plaque, and the NI demonstrated 39.2%; the
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difference was statistically significant (p=0.028). At 12 weeks the BT had 26.3%

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of sites with plaque, and the NI exhibited 45.1% of sites with plaque; the differ-

ence was statistically significant (p=0.0003) (Table 2). When adjusting for baseline

plaque, the difference in plaque scores at four weeks approached, but was not sta-
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tistically significant (p=0.051); however, at 12 weeks the difference was statistical-

ly significant (p=0.0003).

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Analysis of the toothbrush area change from baseline to 4 weeks showed that the

BT group exhibited a mean toothbrush area increase of 6.52 mm2 (SD 21.57),

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whereas the NI group had a mean increase of 14.28 mm2 (SD 29.73). (Figure 3)

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There was an increased deformation in both groups from 4 to 12 weeks. The BT

group exhibited a mean toothbrush area increase from 4to 12 weeks of 12.76 mm²

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(SD 24.07). (Figure 4) The NI group had a mean increase of 22.78 mm² (SD

26.12). With regard to the deformation from baseline to 12 weeks, the BT group
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had a mean increase of 19.91 mm² (SD 41.75). The mean toothbrush area increase
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in the NI group was 37.07 mm² (SD 43.51). (Figure 5)

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Inter-reliability measurements:
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One evaluator (S.P.) consistently showed greater measurements than the other
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(J.H.). The SD of the difference of the measurements between raters was 20.45 and
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the mean was 10.47.

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Discussion

This 12-week prospective randomized clinical trial demonstrates that the BT group

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was significantly more effective in reducing BoP than the NI group. In comparing

the BT group with the NI group for plaque and BoP, the BT group exhibited a sta-

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tistically significant reduction of BoP and plaque from baseline to 4weeks and

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from baseline to 12 weeks when compared with the NI group, which showed an

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increase in plaque and BoP values. AN
A reduction in plaque scores for both groups was expected and occurred. However,
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within the parameter of BoP, the BT group showed a substantial decrease, whereas
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the NI group showed a slight increase. The scrubbing technique 4 seen at baseline
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for both groups, which presumably continued in the NI group, does not allow for

sulcular plaque removal. With a moving bristle tip technique there is little to no
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penetration of the gingival crevice. Additionally, the BT group received oral and
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written brushing instructions at every follow-up visit and showed progressive im-
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provement of BoP and plaque scores, however, the NI group received no brushing

instructions. Considering that 12.5% of the subjects in the NI group were already

using an intrasulcular technique at baseline, the difference between the two groups
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over time is even more significant than if those in the NI group were all using a

non-sulcular technique.

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It might appear paradoxical that in both groups, the percentage of sites with plaque

was greater than the percentage of sites with BoP. The fact that there was stainable

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plaque on the teeth does not mean that the plaque was mature enough to cause tis-

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sue breakdown, thus its presence is not necessarily related to inflammation

(BoP).33,34

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Regarding toothbrush deformation, there were no statistically significant differ-

ences between groups when measuring the area change of the bristle tips. Howev-
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er, the change in deformation in the NI group from baseline to 12 weeks was great-
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er than the change observed in the BT group. One might speculate that the defor-
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mation of the bristles in the NI group hindered the bristles from entering into the

gingival crevice, which might in part account for the greater percentage of sites
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with BoP when compared with the BT group.

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Despite the high level of evidence obtained from this single- blinded, double -

armed, randomized controlled trial, this study has some limitations. The blinded

evaluators who measured the toothbrush deformation had to manually trace the pe-

rimeter of the bristles, which could have led to human error.

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Within the limitations, this is the first study using BoP to show a significant reduc-

tion in gingival inflammation with a specific tooth brushing technique. Thus, the

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BT appears to be an optimal technique, especially for patients with periodontal dis-

eases. Educating patients to use an adequate brushing technique will improve oral

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health and contribute to systemic health. Future multi-center randomized, con-

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trolled studies should include a longer periods of follow-up time to fully confirm

the current findings.

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Conclusion

Based on the current study, the BT technique is more effective in reduction of BoP

compared with individuals brushing with no instructions. The change in defor-

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mation in the NI group from baseline to 12 weeks was greater than the one ob-

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served in the BT group. Furthermore, this study illustrates the importance of moti-

vational interviewing and consistent patient technique instruction with an intrasul-

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cular technique. Future multi-centers studies with longer follow-up time are rec-

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ommended to confirm the current findings.
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Compliance with ethical standards:

Compliance with Ethical Standards

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Conflict of Interest: F. Ausenda declares that he has no conflict of interest. N.

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Jeong declares that she has no conflict of interest. P. Arsenault declares that he has

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no conflict of interest. R. Gyurko declares that he has no conflict of interest. M.

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Finkelman declares that he has no conflict of interest. I. Dragan declares that she
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has no conflict of interest. P. Levi declares that he has no conflict of interest.
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Funding: This study was partially funded by Procter and Gamble (P&G) through a
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donation to the Department of Periodontology at TUSDM and donation of oral hy-

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giene tools.
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Ethical approval: All procedures performed in studies involving human partici-

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pants were in accordance with the ethical standards of the institutional and/or na-
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tional research committee and with the 1964 Helsinki declaration and its later

amendments or comparable ethical standards.

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Informed consent: Informed consent was obtained from all individual participants

included in the study.

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Acknowledgements:

The Authors are grateful to the participants and the staff of the Department of Per-

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iodontology at TUSDM that helped with the logistics. A special thank you goes to

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Dr. Joshua Hall and Dr. Shivam Patel that measured the toothbrush areas.

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Tables, Figures, and Legends:

Figure 1: Examples of standardized pictures of toothbrushes

Figure 2: CONSORT Flow diagram

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Figure 3: Toothbrush Area Change from baseline to four weeks

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Figure 4: Toothbrush Area Change from four weeks to 12 weeks

Figure 5: Toothbrush Area Change from baseline to 12 weeks

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Table 1: Subjects’ “natural” brushing technique at baseline

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Table 2: BoP and Plaque over time
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Table 1: Subjects’ “natural” brushing technique at baseline

Group: Stillman’s Scrub non-sulcular (*) Bass sulcular SBT sulcular Total

BT 1 (4.17%) 20 (10) (83.3%) 0 (0%) 3 (12.5%) 24 (100%)

NI 0 (0%) 21 (9) (87.50%) 1 (4.16%) 2 (8.33%) 24 (100%)

Total 1 (2.08%) 41 (19) (85.42%) 1 (2.08%) 5 (10.42%) 48 (100%)

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*: in parentheses the number of subjects using a Scrub technique along with a Fones’
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Table 2: BoP over time

Baseline One Month Three Months

BoP No BoP Total BoP No BoP Total BoP No BoP Total

BT 320 876 1196 148 1048 1196 132 1008 1140

(26.8%) (73.2%) (100%) (12.4%) (87.6%) (100%) (11.6%) (88.4%) (100%)

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NI 371 949 1320 415 905 1320 578 742 1320
(28.1%) (71.9%) (100%) (31.4%) (68.6%) (100%) (43.8%) (56.2%) (100%)

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Figure 1: Examples of standardized pictures of toothbrushes

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The current images were selected by the authors to highlight

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the standardized technique used for the photography. They also

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with the BT (test) group versus the NI (control) group

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Figure 2: CONSORT Flow diagram

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Figure 3: Toothbrush Area Change from baseline to four weeks

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Figure 4: Toothbrush Area Change from four to 12 weeks

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Figure 5: Toothbrush Area Change from baseline to 12 weeks

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Figure 6: Comparison of clinical measurements between BT (test) and NI (control) groups

A. Bleeding on probing.

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B. Cervical plaque.
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