Use of an Oscillating-Rotating Electric Toothbrush and Novel Brush Head to Increase Brushing Motivation and Reduce Plaque Among Orthodontic Patients

Orthodontic patients are uniquely susceptible to gingivitis, the earliest stage of periodontal disease.¹ The incidence of gingivitis increases throughout childhood and peaks sharply in adolescence because the hormonal changes of puberty enhance the body's inflammatory sensitivity to dental plaque.^2-4 Compounding this challenge to oral health, adolescence is the time during which orthodontic treatment typically starts,⁵ and patients often have trouble cleaning around fixed orthodontic appliances.⁶ This difficulty can lead to increased gingivitis as well as caries and decalcification.⁷

Moreover, the sequelae of poor oral hygiene can compromise the success of orthodontic treatment itself. Bonding of brackets or attachments is often weakened when surrounding tissues are inflamed, bleeding, or producing an increased flow of gingival crevicular fluid.⁸ This weakening can necessitate repairs, sometimes in emergency situations, which increases the overall time to treatment completion. These additional appointments are often irritating for patients, their caregivers, and the orthodontic care team, and reduce the profitability of each appointment. As the use of fixed orthodontic appliances remains prevalent,⁹ especially among young patients,¹⁰ maintaining healthy teeth and tissues with effective plaque control remains a critical component of successful orthodontic treatment.

The long-accepted key to controlling plaque, and thereby gingivitis,^11,12 is mechanical plaque removal by toothbrushing.^12-14 Multiple studies have shown that these goals are best accomplished with electric oscillating-rotating (O-R) toothbrushes rather than with manual toothbrushes^15,16 or other electric brushes.^16,17 In particular, electric toothbrushes with O-R movement have demonstrated robust performance in removing plaque in adolescent patients with fixed orthodontic appliances.^18,19

In 2020, a novel O-R toothbrush (Oral-B iO) with several next-generation features was introduced to the market. The redesigned motor uses a linear magnetic drive that produces micro-vibrations, resulting in Oral-B's most advanced cleaning capabilities with a quieter brushing experience.²⁰ Artificial intelligence technology with real-time, 3D teeth tracking and a smart pressure sensor allows this brush to provide individualized coaching to the user. The Oral-B iO toothbrush has consistently demonstrated statistically significantly greater performance in plaque removal and the achievement of gingival health compared to manual and electric sonic toothbrush controls in assessments ranging from single use to 6 months.^20-23

The latest brush head introduced for the Oral-B iO is Oral-B Targeted Clean. The brush head is designed with longer center-tuft bristles and high bristle density outer tufts to effectively access and clean areas that require special focus, such as around misaligned/crowded teeth, braces, and implants. As with all oral hygiene products, effectiveness depends on patient compliance, which can be problematic among orthodontic patients.^7,24

This practice-based study was designed to assess the effect of the Oral-B iO toothbrush and Targeted Clean brush head on patients' plaque accumulation and motivation to brush over a 9- to 14-week period in patients with fixed orthodontic appliances and a history of poor oral hygiene. The five enrolled patients ranged in age from 9 to 22 years, and all had active fixed orthodontic appliances. Additionally, all patients had poor oral hygiene, as measured with the Ortho Essentials Chairside Laminate Card (Procter & Gamble, dentalcare.ca)²⁵ and defined as a score of 1 at the last two to three orthodontic appointments. Poor oral hygiene was signified by erythematous gingivae with spontaneous bleeding with the presence of oral biofilm (plaque). White-spot lesions and demineralization were also common concomitant findings. All patients formally consented to participate in the study and to try the novel O-R electric toothbrush (Oral-B iO). Patient demographics are summarized in Table 1.

Patients were instructed to use the O-R toothbrush with either the Oral-B Ultimate Clean or the Oral-B Gentle Care brush head (patient's choice), followed by use of the Oral-B Targeted Clean brush head. They continued using their normal toothpaste and/or rinse without any coaching on product.

At the beginning and end of case study participation, each patient's motivation and estimated daily brushing time were assessed using a six-question patient survey. The motivation scale ranged from 1 to 5, with 1 being the least motivated and 5 being the most motivated. In addition, each patient's plaque was disclosed along the gingival margin and between brackets and wires with plaque-disclosing gel (GC Tri Plaque ID Gel^™, GC America, gcamerica.com) and assessed by a dental professional. To accomplish this, orthodontic wires were removed, and the plaque-disclosing gel was applied to the tooth surfaces with a microbrush. After the patient rinsed their mouth lightly with water, photographic records were made of the disclosed plaque. This gel was designed to render freshly accumulated plaque pink or red; plaque that was at least 48 hours old, purple or blue; and mature plaque that produced strong acid, light blue.²⁶ At the conclusion of the study, subjects participated in an exit interview that included the motivation survey.

Clinical observations. At the beginning of the case series, all patients exhibited purple and light blue disclosed plaque, indicative of mature, acid-producing biofilm. At the final visit, 9 to 14 weeks later, mature, strong acid-forming plaque was dramatically reduced. In addition, the total surface area covered with plaque was reduced in all patients, with an approximate mean reduction of 34% (range 15% to 45%). Figure 1 and Figure 2 illustrate visibly reduced plaque for patient No. 3 over 9 weeks. Plaque assessment results are summarized in Table 2.

Survey and interview results. Patients were eager to try the Oral-B iO O-R toothbrush and novel Targeted Clean brush head despite the challenges of fixed orthodontia. By the end of the research, patients reported that they greatly enjoyed the O-R toothbrush and novel brush head. Survey data showed that most patients experienced an increased motivation to brush their teeth, with the mean motivation score increasing from 3 to 4. Parents and caregivers reported that their child was re-engaged in managing their own oral health and consequently required less coaxing to brush. Self-reported mean brushing time was relatively flat during the evaluation period (2:34 to 2:42 minutes), increasing by 8 seconds, but the substantial decrease in plaque levels demonstrates the highly efficient plaque removal provided by the brush and novel brush head. Results of the patient survey are summarized in Table 3.

In this practice-based research involving five patient cases, use of the O-R electric toothbrush and novel brush head was associated with both objective and subjective improvements in at-home oral hygiene. This is a meaningful achievement in oral care for orthodontic patients, for whom plaque removal is uniquely difficult and important.

Among orthodontic appliances, fixed appliances make mechanical cleaning particularly difficult and thereby pose multiple health challenges. In comparison with removable appliances, fixed appliances are associated with significantly greater cariogenic oral bacteria²⁷ and worse periodontal health.^28-30 Furthermore, these outcomes can negatively affect orthodontic treatment when fluid from diseased tissue weakens orthodontic bonding.⁸ This often results in extra appointments, longer treatment times, and reduced patient satisfaction. Effective biofilm control in orthodontic patients not only preserves overall oral health in this high-risk population, but also helps to optimize the orthodontic treatment process and outcome.

By the end of this case series, use of the O-R toothbrush with micro-vibrations, combined with a novel brush head designed for cleaning hard-to-reach areas, consistently reduced both overall plaque coverage and the proportion of mature plaque in patients with fixed orthodontic appliances after 9 to 14 weeks of brush use. Moreover, this brush aided orthodontic patients in overcoming the tendency to neglect proper oral hygiene,^7,24 as most patients in this study reported increased motivation to brush, and this attitude shift was confirmed by their caregivers.

Orthodontic patients have unique oral care needs. Ineffective brushes, as well as effective brushes that patients are not motivated to use, leave patients' oral health and orthodontic care at risk. By recommending this brush and novel brush head, providers can match orthodontic patients with a personalized tool to optimize their home oral care routine.

This case series evaluation, which was intended to complement the existing body of clinical evidence for O-R toothbrush technology, demonstrates that the O-R electric toothbrush and novel brush head improved patients' oral hygiene, showing highly efficient plaque removal, and had positive effects on motivation to brush. Offering superior cleaning, real-time user feedback, and a record of usage over time, this brush and brush head are an excellent choice for orthodontic patients.

The author thanks Marisa DeNoble Loeffler, MS, for medical writing assistance in the preparation of this manuscript. Medical writing assistance was funded by Procter & Gamble.

This case series was supported by Procter & Gamble. Dr. Van Elslande has done consulting work for Procter & Gamble..

Dana Van Elslande, DDS, MSc
Private Practice in Orthodontics, Calgary, Canada