Historical Review of Toothbrushes in the United States. Review & Commentary

Transcription

1 Review & Commentary Ergonomics and Toothbrushes Christine Hovliaras Professional Savvy, LLC Flanders, NJ, USA John Gatzemeyer Eduardo Jimenez Fotinos S. Panagakos Colgate-Palmolive Company Piscataway, NJ, USA Introduction The toothbrush is an essential oral hygiene tool that patients use to clean the surfaces of their teeth and remove plaque biofilm from the gumline, preventing oral diseases such as dental caries, gingivitis, and periodontitis. In this article, we will discuss the ergonomic research in the design of both manual and powered toothbrushes. Before we get into the research that has been published, we will provide a brief overview on the history of both manual and powered toothbrushes in the United States. Historical Review of Toothbrushes in the United States Manual Toothbrushes In 1857, the first manual toothbrush in the United States was developed and patented (registered as patent number 18,653) by Henry Wadsworth. 1 The toothbrush was constructed from a bone handle with holes placed to hold Siberian boar swine hair. This toothbrush was mass produced in 1885 and used until ,2 In 1938, DuPont replaced the animal hair bristles with the first nylon bristles. 1 During the 1900s, bone handles were replaced by celluloid. Toothbrush design was simple, with straight handles and toothbrush heads with flat-trimmed bristles. By the 1950s, softer nylon bristle toothbrushes were manufactured, and from the 1960s through to the 1980s toothbrushes were available in a variety of shapes and sizes. Variations included bristle shape, size, and texture, as well as unconventional handle styles. 3 In 1983, the Colgate-Palmolive Company introduced the Colgate Plus toothbrush with two levels of bristles that contoured over the teeth to clean tooth surfaces and interproximal spaces. The diamond-shaped head permitted easier access to back teeth and the rubber-gripped handle allowed better manipulation. In the mid- 1980s, the Johnson & Johnson Company launched the Reach toothbrush, which had an angled head to reach back molar teeth and a bristle design with denser tuft placement to enhance cleaning of each tooth. The outer bristles were higher and had a softer consistency to assist in cleaning between the teeth. In 1993, Oral-B introduced its own line of larger-handle toothbrushes, though there were challenges. Following the launch, Dr. Paul Warren from Oral-B reported, that many consumers thought the toothbrushes were handy, but they didn t fit into the bathroom toothbrush holder. So Oral-B developed a toothbrush holder which looked like a cigar case that could be left on the counter or packed when traveling. 4 Since these early introductions, many oral care companies have produced additional toothbrush variations (e.g., angled toothbrush heads, multi-leveled bristles, rounded smooth bristles) to provide functional design features to assist consumers in a more effective cleaning of their teeth between dental visits. Powered Toothbrushes The first electric toothbrush was introduced in the United States in 1959 by E.R. Squibb and Sons Pharmaceuticals under the names of Broxo-Dent or Broxodent. In the early 1960s, the General Electric Automatic Toothbrush was launched, which was cordless and had rechargeable NiCad batteries and a charging stand. In 1978, the Oral-BD-1 became the first mass-produced power toothbrush with a manual-like toothbrush head and a side-to-side motion. In 1991, the Oral-BPlaque Remover D5 was developed, utilizing an oscillating-rotating mode of action. The brush had a cup-shaped head with end-rounded bristles to provide enhanced plaque removal versus a manual toothbrush. The brush also included a two-minute light timer to ensure consumers brushed for the amount of time recommended by the dentist. 5,6 The range of Oral-B power toothbrushes is based on a clinically proven oscillating and rotating action. The three-dimensional brush head action (oscillating, rotating, and pulsating), common to the Oral-B Professional Care Series in the D15 and D17 models, is proven in both laboratory and clinical testing. Laboratory studies showed that additional pulsating action and advancements in filament technology improved approximal penetration. Results of clinical trials in the development program show the superiority of the D15 and D17 models with 3D action over a manual toothbrush and other powered toothbrushes of various actions/designs in the improvement of oral health outcomes on plaque removal, gingival inflammation, calculus, and stain formation. 7 In 1992, the Optiva Corporation launched the Sonicare sonic electric toothbrush, which had high frequency power toothbrush technology that represented this brand for a decade. In 2000, Optiva was acquired by Philips, which introduced the second generation Sonicare Elite in 2002 with a new brush head that had a bristle trim that fit the contour of the dentition. The head was angled to reach molar teeth, with an oscillating, twisting rotation of the brush head that provided a sweeping bristle motion. 8 Oral-B then launched the Sonic Complete in 2004 followed by Pulsonic in 2008, which targeted consumers who favored sonic brushes with a quieter, slimmer/lighter option and one that provided maximum cleaning performance. 9 Sonicare FlexCare was introduced in 2007 with a simplified brush head and handle interface to make cleaning and changing brush heads easier using a pull-and-push action. 8 28

2 Other power and sonic toothbrushes were commercially introduced into the market, with modifications to their appearance and features they provide to consumers, including ergonomic design, brushing modes, timers for quadrant brushing, and brushing force monitors. A 2011 industry analysis estimated that at least one-third of all toothbrush expenditures were on power toothbrushes in the United States.10,11 In 2012, a new powered toothbrush, the Colgate ProClinical A1500 was launched by the Colgate-Palmolive Company. This new power toothbrush provides multi-directional brush head movement for optimized brushing action on three separate surfaces in the mouth (occlusal surfaces, gingival margins, and facial/lingual surfaces) when held at different angles. The toothbrush adjusts the frequency of sonic action and motion of the head depending on the surface being cleaned. The ergonomic features of this new electric toothbrush will be discussed later in this article. Ergonomics and Toothbrushes Ergonomics refers to the application of scientific knowledge from the fields of anatomy, physiology, mechanics, and psychology to utilize human energy most effectively. This human energy could include communication and interaction with people, materials they use at home and work, and how the physical and mental issues of their job affect them as a person. Ergonomically developed items, from furniture that people use in their homes to chairs that people utilize in the workplace and toothbrushes that people use to clean their teeth and gums, are Figure 1. The Colgate 360 manual toothbrush launched in Figure reprinted with Figure 2. Four types of toothbrush handle designs.12 Figure reprinted with 29 designed to fit their lifestyle through comfort of use. They should not deter from their behavior and provide a safe and non-threatening environment for their continued use. There is not an abundant amount of research conducted that offers insights into the effect of ergonomics in relation to the use of manual or electric toothbrushes. As practicing dental professionals, we need to recognize that ergonomics plays a vital role in helping patients to comply with oral hygiene care after their visit for a regular professional cleaning and oral examination. In the manual toothbrush category, ergonomic elements include the handle and grip design, angulation of the toothbrush head, the design of the toothbrush head to reach posterior teeth, and toothbrush bristles being able to reach the gumline and interproximal spaces to remove plaque biofilm and food debris. Colgate 360 Manual Toothbrush Several papers have been cited in the literature regarding ergonomic features and development of an improved manual toothbrush to provide convenience and cleaning effectiveness for the consumer.12,13 These ergonomic elements, incorporated into the design of the Colgate 360 manual toothbrush (Figure 1), include:12 1) Handle design Assists with ease of brushing and helps patient compliance when brushing. A handle with an offset or an angled offset design provides contact in line with the longitudinal axis of the handle during tooth brushing (Figure 2). 2) Toothbrush bristle configuration Three cups in the center of the toothbrush bristle area would help to retain dentifrice Figure 3. Close up of three polishing cups at the center of the Colgate 360 manual toothbrush head.12 Figure reprinted with Figure 4. Side view of Colgate 360 manual toothbrush with pointed outer tufts and at the anterior tip of the toothbrush head.12 Figure reprinted with

3 30 in and around the central tufts to allow more effective cleaning on the tooth surface and to help remove extrinsic surface stains (Figure 3). 3) Tall thin pointed outer bristle tufts These tufts were added to the outside rows of the bristles to help in removing plaque along the gingival margin and interproximally, as well as at the tip of the toothbrush for cleaning posterior teeth (Figure 4). It is noteworthy that Hohlbein, et al. reported that consumers perceived that having raised bristle tufts at the tip of a toothbrush could help in the removal of plaque in posterior teeth and on the lingual surfaces of teeth.12 4) Handle grip A textured, gel-like grip to improve stability and manipulation of the toothbrush during brushing (Figure 5). The same ergonomic elements mentioned for manual toothbrushes are also important for electric toothbrushes. Additional elements to consider for electric toothbrushes include: 1) is the device easy to turn on and off; 2) what are the brushing speeds offered to the user; 3) if changes in brushing speed provide feedback (audible or tactile); 4) what these brushing speeds mean during tooth brushing; 5) rechargeability of the toothbrush device; and 6) the size of the toothbrush and holder with regard to storage and use in the bathroom at home. Colgate ProClinical A1500 Powered Toothbrush Colgate-Palmolive Company launched the ProClinical A1500 powered toothbrush in the Fall of 2012 (Figure 6). This powered toothbrush provides a technology that allows high frequency brush strokes in three modes (Auto, Optimum, Deep Clean) which operate at a frequency range between 20,000 and 32,500 strokes per minute to provide the user with a superior clean when brushing the teeth and gumline.14 The Three Brushing Modes This powered toothbrush provides the latest technology in the Auto Mode, that allows the powered toothbrush to adjust its speed based upon how the consumer moves the handle in any direction in the oral cavity without having to change the speed manually. This is an exceptional ergonomic option that allows this toothbrush to do the work of brushing, allowing for a more pleasant brushing experience while assisting the patient in improving their oral health. When brushing the buccal and lingual surfaces of the teeth, the Colgate ProClinical A1500 will be on low-speed and the head will have a back and forth sweeping motion. The Optimum Mode of this powered toothbrush operates at midspeed at a frequency of 27,000 strokes per minute, utilizing up-down and side-to-side strokes to clean plaque and food debris along the gumline at a 45 angle. The brush utilizes an LED display that lights up on the handle above the Auto Mode button when the consumer is brushing at the 45 angle along the gumline14 (Figure 7). The Deep Clean Mode operates at a frequency of 32,500 strokes per minute with up-down strokes that clean deep in between and behind teeth and the occlusal surfaces of teeth.14 (Figure 8). The Colgate ProClinical A1500 contains accelerometers, which Figure 5. Textured gel-like thumb grip toothbrush handle.12 Figure reprinted with Figure 7. Visual photograph of the Optimum Mode brush head movement operating with up-down and side-toside strokes.14 Figure reprinted with Figure 8. Visual photograph of the Deep Clean Mode brush head movement operating with up-down strokes.14 Figure reprinted with are electric sensors that measure speed of motion and orientation. This is technology similar to that found in today s smartphones and tablets. A control unit in the brush will adjust the speed and action of the toothbrush head based on the feedback from the accelerometer.14 Ergonomic Evaluation of the Colgate ProClinical A1500 Figure 6. The new Colgate ProClinical A1500 powered toothbrush. Figure reprinted with permission from Colgate-Palmolive Company. Tooth Brushing Time Using the Colgate ProClinical A1500 The Colgate ProClinical A1500 is the first powered toothbrush to be evaluated by ergonomic experts, the Metaphase Design Group.

4 31 Two studies were conducted to evaluate the ergonomic elements of this new electric toothbrush and consumer usability. 17,18 The first study compared the Colgate ProClinical A1500 to the Sonicare FlexCare and Oral-B Smart Series electric toothbrushes. Ergonomic experts evaluated the three powered toothbrushes for one week and assessed the following ergonomic principles (grip design, handle length, use of controls, and sound audibility. 17 The ergonomic experts concluded that each of the three electric toothbrushes had adequate grip controls to properly hold the toothbrush and provided easy access to the on/off control button. However, the Colgate ProClinical A1500 had the most distinct feature with its longitudinal handle shape that angles downward from the top to provide additional control when gripping the toothbrush and improved ability to see the brushing area in the mouth. (Figure 9). The Colgate ProClinical A1500 also provides ease of use with its changing speeds when used in the mouth, brush movements and change in sound during changes in brushing speeds. 17 Design of the Toothbrush Handle and Toothbrush Head The Colgate ProClinical A1500 has a cylindrical-shaped handle to allow the patients to easily manipulate and rotate it while brushing (Figure 9). A shank portion angles downward at the top of the handle to allow the user to more easily see the operation display on which it is mounted. The brush head remains in line with the handle to position and place the toothbrush in the mouth. The on-off button is easy to access, with the thumb and the brushing modes easy to observe and operate via the display portion (Figure 10). The toothbrush head is somewhat smaller than the majority of the commercially available power toothbrushes on the market, and able to clean hard-to-reach areas in the posterior of the mouth. The tapered outside bristles clean deep along the gingival margin and the inner bristles help to remove plaque from tooth surfaces. 15,16 Timer and 30-Second Pacer This new powered toothbrush allows the patient to brush for the full two-minute period for better cleaning, and offers the 30- second pacer that provides a momentary pause to brush a new quadrant in the mouth. The toothbrush will power down after the recommended 2-minute brushing time. Interchangeable Toothbrush Heads The standard type of head for the Colgate ProClinical A1500 is the triple clean head, which is a standard option for this brush, and a sensitive head for more gentle cleaning. The package provides two of the standard heads and one of the sensitive heads. Rechargeability, Storage, and Portability The Colgate ProClinical A1500 needs to charge for 16 hours before first use, and does not require recharging for at least four to Figure 9. Handle length, shape, and brush heads of the three powered toothbrushes (Colgate ProClinical A1500 at top, the Oral-B Smart Series in the middle and the Philips Sonicare FlexCare at the bottom). 17 Figure reprinted with The second study was a usability study with 14 consumers who used the Colgate ProClinical A1500 twice daily for three weeks. The patients participated in four toothbrush trials that were videotaped during weekly visits to the study site. Patients videotaped themselves brushing with their manual toothbrush at home, which was the baseline evaluation for this study. 18 Patient studies show that most people will brush for less than a minute rather than the two minutes that the American Dental Association advises. 19 Participants who were included in a usability study for a threeweek period did increase the length of the tooth brushing process when using the Colgate ProClinical A1500. When these participants brushed with their manual toothbrush in this study, they brushed for only 54 seconds. However, when they brushed with the Colgate ProClinical A1500, their brushing time averaged 99 to 107 seconds during Trials 1, 2, and 4. The patients had a positive brushing experience in being able to manipulate the Colgate ProClinical A1500 in their mouth and brush in the recommended angle. Additionally, consumers reported that their teeth were cleaner after using the Colgate ProClinical A1500 and the handle was lightweight and easy to maneuver when cleaning the back teeth. 18 Mode Button Power Button Figure 10. Colgate ProClinical A1500 controls and user interface. 17 Figure reprinted with

5 32 five days after use. The device is easy to store on the bathroom counter, taking up very little space. It also has a travel case that permits easy portability. Conclusion Ergonomics plays an important role in the development of both manual and powered toothbrushes, and assisting consumers to adequately brush their teeth to effectively remove plaque biofilm and enhance their oral healthcare. The Colgate ProClinical A1500 is the newest toothbrush technology launched that provides patients important ergonomic features that include grip design, handle length that assists consumers in reaching their back teeth, easy-to-use controls, and differing sounds to identify at which angle they are brushing. This new powered toothbrush guides the patient to where they should be brushing and determines the angle and speed based upon where the patient has the toothbrush head in their mouth. It also allows the patient to brush the buccal and lingual surfaces at a 45 angle to effectively clean the gumline and cervical portion of the teeth surfaces, and reaches the interproximal and occlusal surfaces to effectively clean all areas of the teeth. Patients who have used the Colgate ProClinical A1500 have brushed up to two minutes versus 45 seconds when they used their own manual toothbrush. 18 These patients felt they had cleaner teeth and a positive brushing experience with this new sonic toothbrush. The technology and design incorporated into the Colgate ProClinical A1500, with its distinct multi-directional cleaning action, provides a superior tooth brushing experience for improved patient compliance, comfort, and efficiency for optimal plaque removal and improved oral healthcare. (J Clin Dent 2015;26:28 32) Acknowledgment: Funding for the publication of this review was provided by the Colgate-Palmolive Company. 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