Cross‐angled versus flat‐trim bristle tuft... : International Journal of Dental Hygiene (2025)

1 INTRODUCTION

Periodontal diseases and dental caries are prevalent conditions among humans and are the primary factors leading to tooth loss., Both are complex chronic diseases and share common risk factors, such as the presence of dental plaque biofilm. A significant proportion of tooth loss and impaired chewing function can be attributed to periodontitis, which may adversely affect overall health and incur substantial dental care expenses. Gingivitis plays a critical role as a primary risk factor and an essential precursor to the development of periodontitis. Consequently, the primary preventive approach for periodontitis involves effectively managing gingivitis., Dental plaque‐induced gingivitis can be reversed by reducing plaque levels at and apical to the gingival margin.,

There are multiple methods for mechanically removing dental plaque from teeth. The utilization of a toothbrush is widely regarded as the most effective approach., , Various systematic reviews (SRs) have evaluated the efficacy of manual toothbrushes (MTBs) and powered toothbrushes (PTBs)., , , In general, they conclude that PTBs are more effective than MTBs in reducing dental plaque,, gingivitis, and bleeding., Recently, an SR with a network meta‐analysis on this topic concluded, based on the outcome of single acts of brushing, that for dental plaque removal, there is a high certainty of a small effect of PTB efficiency compared to an MTB. Despite this, the clinical relevance remains unclear. In addition, the MTB remains popular as it is generally more affordable and is the most commonly used oral hygiene aid worldwide.

MTBs can have various toothbrush configurations, including flat‐trim (FT‐TB), multilevel, and cross‐angled designs (CA‐TB). The standard manual toothbrush is typically an FT‐TB with conventional vertical bristles. Modern toothbrushes incorporate bristle patterns and brush head designs that aim to compensate for suboptimal toothbrushing techniques. These designs are developed under the assumption that a significant proportion of the population utilizes a basic horizontal brushing motion during oral hygiene practices. High‐speed photography has shown that while the sweeping motion of vertical bristles is effective on smooth tooth surfaces, penetration of interproximal areas is poor. The toothbrush filaments achieve their maximum interproximal penetration when the brushing direction is altered. Bristles that sweep across the tooth surface in one direction curve back into the interproximal space, moving downward and then upward along the adjacent approximal surface. However, with conventional vertical bristles, this phenomenon is restricted as only a few bristles are appropriately positioned at the interproximal junction when the brush changes direction. The design of toothbrushes with a cross‐angled bristle orientation deviates from the conventional toothbrush design by incorporating tufts angled in opposite directions. This bristle arrangement is believed to enhance approximal penetration, resulting in more effective removal of plaque, particularly from interproximal surfaces and the gum line. Laboratory studies have demonstrated that as the bristle angle exceeds 12°, the bristles penetrate more deeply and frequently, thereby improving the cleaning efficiency.

A systematic review based on 212 brushing exercise experiments involving 10,806 participants showed that following brushing with an MTB, an average 42% plaque score reduction can be expected. Sub‐analysis on bristle tuft arrangement indicated that an angled configuration may be more effective. In numerical terms, the angled bristle design exhibited the highest average reduction in plaque scores. However, the absence of a direct comparison limits the ability to make definitive claims.

The objective of the present study is to conduct a systematic evaluation of the existing clinical evidence regarding the comparison between a conventional manual flat‐trimmed toothbrush and a toothbrush with a cross‐angled bristle tuft. The study evaluates these toothbrushes in relation to plaque scores and parameters related to gingival health in adult patients.

2 MATERIALS AND METHODS

This systematic review was prepared and described in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and the guidelines provided in Transparent Reporting of Systematic Reviews and Meta‐analyses (PRISMA‐statement)., , The protocol that details the review method was developed a priori after an initial discussion among the members of the research team. The review is registered with the International Prospective Register of Systematic Reviews (PROSPERO) under number CRD42021278680. The study was also approved by the Institutional Review Board of the Academic Center for Dentistry Amsterdam, the Netherlands, under number 2020‐298.

2.1 Focused PICOS question

Based on randomized controlled clinical trials, what is the effect of a manual toothbrush with a cross‐angled bristle configuration compared to a manual toothbrush with a flat‐trim design on plaque, bleeding, and gingival index scores? In addition, what are the adverse effects on soft and hard tissue?

2.2 Search strategy

A structured and comprehensive search strategy was designed to retrieve all relevant publications that satisfied the study purpose with a direct comparison between the CA‐TB and the FT‐TB. Electronic databases were searched for relevant papers. These included The National Library of Medicine in Washington, D.C. (MEDLINE‐PubMed), and the Cochrane Central Register of Controlled Trials (CENTRAL). The last electronic search update was performed on 1 August 2023. The search strategy and employed search terms and keywords are presented in Table 1. All references cited in the papers selected for this review were checked for additional potentially suitable studies. Hand searching was only performed as part of the Cochrane Worldwide Hand Searching Program uploaded to CENTRAL.

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2.3 Screening and selection

Titles and abstracts of the studies obtained from the searches were screened in detail for suitability by two reviewers (TMJAT, DES) using the Rayyan web application. The reviewers worked independently and were blinded to each other's results during the screening process. Possible duplicates were identified and checked to eliminate identical ones. Disagreements in the screening and selection process were resolved by consensus or, if disagreement persisted, by arbitration through a third reviewer (GAW). The papers that fulfilled all the inclusion criteria were processed for data extraction.

Studies were deemed eligible for inclusion if they conformed to the following criteria:

  1. Publications written in English

  2. Full publications (no conference abstracts)

  3. (Randomized) Controlled Clinical Trials (CCT or RCT)

  4. Studies conducted with human participants:

    1. ≥18 years old

    2. In good general health (without systemic disorder or pregnancy)

    3. Without diagnosed periodontitis

    4. Without orthodontic fixed appliance

    5. Without removable prosthesis

    6. Without dental implants

  5. Self‐performed brushing by the participant

  6. Brushing time for intervention and comparison were the same

  7. Comparison of interests:

    1. Intervention; manual toothbrush with cross‐angled bristle configuration (CA‐TB)

    2. Comparison; manual toothbrush with flat‐trim bristle design (FT‐TB)

  8. Outcome parameters of interest:

    1. Primary: gingival scores, plaque scores, bleeding scores

    2. In addition, if provided, secondary: adverse effects such as soft and hard‐tissue trauma

  9. Study duration and outcome parameters of interest:

    1. Single brushing action studies: plaque

    2. Longer‐term studies with a minimum duration of 4 weeks: plaque, bleeding, gingivitis.

2.4 Heterogeneity assessment

Across the studies, clinical and methodological heterogeneity were assessed. The diversity of study designs was used for the evaluation of methodological heterogeneity. Clinical heterogeneity was evaluated as follows: characteristics of participants and groups; variations in toothbrush design/brands; regimen and instructions; and variations in indices used for outcome parameters.

2.5 Methodological quality assessment

Two reviewers (TMJAT and DES) individually scored the methodological qualities of the included studies according to the method described by Van der Weijden et al., and in greater detail by Keukenmeester et al. In summary, the study was classified as having an estimated ‘low risk of bias’ when random allocation, defined eligibility criteria, masking of examiners, masking of patients, balanced experimental groups, identical treatment between groups (except for the intervention), and reporting of follow‐up were present. The study was considered to have an estimated ‘moderate risk of bias’ when one of these seven criteria was missing. When two or more of these criteria were missing, the study was estimated to have a ‘high risk of bias’. The potential risk of bias was estimated, and the acquired evidence was graded.

For the present review, the risk of bias and the assessment were checked for each included study by the two reviewers. If disagreements in the quality assessments were found, this was resolved by consensus after discussion; if it persisted, consensus was reached through a third reviewer (GAW). Separately, five ethical aspects were scored to explore whether the publications adhered to general ethical guidelines, such as funding and potential conflicts of interest.

2.6 Statistical analysis

2.6.1 Data extraction

The data from the publications that met the selection criteria were extracted and processed for further data analysis. Custom‐designed data extraction forms were used by two independent reviewers (TMJA and DES). Data of interest are for the single brushing action studies involved pre‐ and post‐brushing and incremental change of the plaque score data. For the longer‐term studies, baseline‐, end‐, and difference scores were evaluated. Data were extracted as means and standard deviations (SDs). If studies provided a standard error (SE) of the mean, these values were converted to SD based on the sample size (SE = SD/√N). In all cases, to ensure an accurate estimate, any data approximation in figures was avoided. In case of missing data or undetermined information, attempts were made to contact the first or corresponding author of the included publications for clarification or to retrieve additional data. Disagreements in the extracted data were resolved by discussion and consensus.

2.6.2 Data analysis

A descriptive data presentation was used for all studies. A meta‐analysis was performed where appropriate, and differences in means (DiffM) or standardized mean differences (SMD) were calculated using the Review Manager 5.4.1 software (RevMan version 5.4.1, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2020) with either the ‘fixed’ or ‘random effects’ model, as appropriate. The 95% confidence interval (CI) is presented for both the SMD and the DiffM. The continuous measurement effect size SMD is known as Cohen's d. The magnitude of the effect was interpreted as small; 0.2, medium; 0.5 and large; 0.8 (Table S12).

To test whether the results of the various studies were homogenous, the studies' heterogeneity was assessed by the chi‐squared test and I2 statistic during the meta‐analysis. A chi‐squared test resulting in p < 0.1 was considered an indication of significant statistical heterogeneity. I2 yields a quantitative indication of the comparability of studies in a meta‐analysis. As a rough guide, I2 was interpreted as follows: an I2 of 0%–40% may indicate unimportant levels of heterogeneity; an I2 of 30%–60% may represent moderate heterogeneity; an I2 of 50%–90% may represent substantial heterogeneity; and an I2 greater than 75% may indicate considerable heterogeneity (Table S13).

2.7 Grading the body of evidence

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, as proposed by the GRADE working group, was used to rank the body of evidence emerging from this review. Two reviewers (TMJA and DES) rated the quality of the evidence and the strength of the recommendations., Any disagreement between the reviewers was resolved after additional discussion.

3 RESULTS

3.1 Search and selection

A search of the databases identified 200 unique studies (for details, see Figure 1). Screening of titles and abstracts resulted in 22 potentially relevant papers, which were obtained in full text. After careful, extensive, and detailed reading, 14 studies were excluded (for details, see Appendix S1). This resulted in eight studies, , , , , , , for inclusion in this review, describing in total 19 comparisons (for details, see Figure 1). Three of the included studies (I–III), , were categorized as short‐term (single brushing action) and five (IV–VIII), , , , were considered longer‐term (use over a minimum period of 4 weeks). All the included studies evaluated one or more of the primary and clinical parameters.

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3.2 Assessment of clinical heterogeneity

The characteristics of each study are displayed in Table 2a,b. The number of included participants varied, from 30 up to 112, and the age ranged from 18 to 67. In two studies (VII, VIII),, the participants were dental students.

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The included studies presented varying degrees of gingival inflammation, but none of the participants had periodontitis. The criteria for gingivitis were not described, only Ren et al. (VI) used a minimum S&L gingival index 1.

Most included studies used the Oral‐B CrossAction as the CA‐TB (I, II, VIII), , and/or one of the other Oral‐B Cross‐Angled (Oral‐B Exceed, Oral‐B CrossAction Pro‐health, Pro‐expert, Ultrathin or Vitalizer) (II, III, V, VII)., , , One study used the Elmex InterX as the CA‐TB (IV), and one study used the Elmex Sensitive (Soft/Extra Soft) (VI). The Oral‐B indicator (I, II, III, V, VII),, , , , the ADA flat trim (IV, VI),, and the Butler 411 (VIII) were used as the control FT‐TB.

In more than half of the included studies (IV, V, VII, VIII),, , , participants received oral hygiene instructions. In one of these studies, only half of the participants of each treatment group received oral hygiene instructions (IV). In two studies (VII, VIII),, instruction in the (modified) bass technique was given. In the remaining studies (IV, V),, the technique participants received instructions in was unspecified. In the majority of the short‐term studies (I–IV),, , , participants were instructed to brush for 1 min without using a mirror. With regard to the long‐term studies (IV–VIII),, , , , participants were instructed to brush twice daily, and in some studies, (VIII) a duration of 2 min was specified (for details see Table 2).

3.2.1 Plaque, bleeding, and gingival indices

Plaque scores were assessed in all of the included studies. One study evaluated outcome parameters on a selected number of teeth (V), and the remaining studies performed full mouth assessments. The most commonly used plaque index was the Turesky Modification of the Quiqley and Hein Plaque Index (TQHPI), (III–VII),, , , , followed by the Rustogi et al. Modified Navy Plaque Index (RMNPI) (II), Proximal/Marginal Plaque Index (PMI) (I), and PI by Silness & Löe (VIII). In five studies (IV–VIII),, , , , clinical parameters of gingivitis were also evaluated. Additionally, safety assessment was included in some studies (IV, VI, VII)., , The Eastman bleeding index (IV) and bleeding on pocket probing (BoP) (VII), were used to evaluate bleeding scores. In all studies assessing the gingival index, the index by Löe and Silness was used (IV, VI–VIII)., , ,

3.2.2 Funding and conflict of interest

The authors of two studies declared no conflict of interest (III, VIII)., Four studies (I, II, V), , included the disclaimer that the authors were affiliated with the manufacturer of Oral‐B toothbrushes, Procter & Gamble. Two studies were funded by GABA International AG (IV, VI)., The remaining study (VII) did not report information on conflict of interest or funding.

3.2.3 Adverse effects

Six studies (I, III–VII), , evaluated the safety of the toothbrushes. No major adverse events were detected related to toothbrush use in any of these studies. No hard or soft tissue abnormalities were detected and no signs of irritation. Only mild tooth sensitivity was reported in one case (V), possibly related to treatment in the CA‐TB group. In one study (VII), gingival recession was evaluated and reported no pronounced effects of the bristle design.

3.3 Assessment of methodological heterogeneity

All the included studies were designed as single‐blinded randomized controlled trials. Three (V–VII), , had a parallel‐group design, and five (I–III, V, VIII), , , , had a cross‐over design.

3.4 Assessment of methodological quality

A summary of the evaluation of the risk of bias in the individual studies is shown in Table S2. Based on a summary of the proposed criteria, the potential risk of bias was estimated to be moderate for Pizzo et al. (III) studies and low in the remaining seven studies (I, II, IV–VIII), , , , , , (for details, see Table S2).

3.5 Study outcome results

Table S3a–c presents the results of the data extraction performed on the selected studies in various clinical indices. Where available, the baseline, end scores, and incremental changes between baseline and end scores are presented. The extracted data are presented by means and SD separately per outcome parameter and sorted by index of interest (Table S3a–c).

3.5.1 Descriptive analysis

In Table 3, a summary of statistically significant differences is presented for the outcomes of interest for short‐ and long‐term based on scores of all tooth surfaces assessed. In Table S11, the sub‐analysis is shown solely for the gingival area or approximal surfaces of assessed teeth.

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In total, seven (I–IV, VI), , , , of 11 comparisons showed a significant difference in plaque reduction in favour of the toothbrush with cross‐angled bristle design. Three studies (V, VI, VIII), , showed no difference in plaque removal between the CA‐TB and FT‐TBs. One study presented insufficient data for analysis (V). Regarding longer‐term plaque scores, all three Elmex® CA‐TBs (E/CA‐TB) displayed statistically significant differences from FT‐TBs, while the three Oral‐B® CA‐TBs (OB/CA‐TB) did not.

Concerning the gingival index scores, in three studies (IV, VII, VIII),, , no significant difference was found. In two studies, with three comparisons (V, VI),, there was a significant difference in gingival index scores in favour of the cross‐angled toothbrush. The results for bleeding on probing were inconclusive, as one study (VII) showed no significant difference for this parameter and another (IV) indicated a significant difference in favour of the cross‐angled toothbrush.

3.5.2 Meta‐analysis

Meta‐analysis was possible for the outcome parameters plaque, bleeding, and gingival index scores. Table 5 and Tables S4–S11 provide the results of the meta‐analysis. Subgroup analysis was possible for two indices in long‐term studies regarding plaque scores and gingival index scores: the TQHPI, and the Löe & Silness (Table 4).

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Single‐brushing studies

At baseline, the meta‐analysis showed no statistically significant standard mean difference (SMD) between full mouth plaque scores of the comparisons of CA‐TB and FT‐TB (SMD = 0.01; 95% CI (−0.16; 0.18)). The mean post‐brushing scores were in favour of the CA‐TB (SMD = −0.62; 95% CI (−0.95; −0.30)) (Table 5). Analysis of the mean outcomes on incremental plaque score reduction showed this to be in favour of CA‐TB (SMD = 0.75; 95% CI (0.51; 0.99)). Both are interpreted as a medium‐magnitude effect. This aligns with the mean gingival and approximal plaque scores, which were significantly different in favour of the CA‐TB (SMD = 0.64; 95% CI (0.37; 0.91), and SMD = 0.51; 95% CI (0.34; 0.69)), respectively (see Appendix S9). The corresponding forest plots are displayed in Appendix S4a–i.

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Longer‐term

Meta‐analysis of longer‐term studies was conducted for the overall plaque scores, bleeding scores and gingival index scores. Standard mean differences were not statistically significant for baseline and end scores for all parameters (Table 5).

Subgroup analysis was feasible for two specific indices (TQHPI, and Löe & Silness GI), as shown in Table 4, and for toothbrush brands (E/CA‐TB and OB/CA‐TB) (see Appendix S10). Sub‐analysis of TQHPI, data included four comparisons from three studies (V–VII)., , The DiffM for baseline and end plaque scores showed no statistically significant difference.

Further sub‐analysis for the Löe & Silness GI included data from three studies (IV, VI, VII), , presenting four comparisons. There were no significant DiffM in gingival index scores at the end of the studies. However, there appeared to be significant DiffMin gingival index scores at baseline, with the FT‐TB group having a higher score than the CA‐TB group.

The sub‐analysis by toothbrush brand showed contrasting results on end plaque scores. The Elmex® studies favoured the CA‐TB (SMD = −0.52; 95% CI (−0.79; −0.25)), while the studies including the Oral‐B® favoured the FT‐TB (SMD = 0.36; 95% CI (0.08;0.64)). However, in both sub‐analyses, the baseline scores showed a statistically significant DiffM.

For end gingival index scores, both brands showed a statistically significant DiffM in favour of CA‐TB, while mean baseline scores were not significantly different. The corresponding forest plots are displayed in Appendices S5e–h and S7e–h.

3.6 Assessment of statistical heterogeneity

The studies included in the meta‐analysis for the single‐brushing studies showed a moderate to substantial heterogeneity, as I2 statistic values ranged from 0.0%–71% (Table 4). When only considering the longer‐term studies, a moderate to substantial heterogeneity (0.0%–87%) was present.

3.7 Evidence profile

Table 6 shows the evidence profile based on a summary of the various factors used to rate the quality of evidence and the level of certainty. The table gives an estimation of the strength and direction of the recommendation according to GRADE, In the short term, there is a weak certainty to recommend the CA‐TB over the FT‐TB as there seems to be a slight beneficial effect. The magnitude of the effect was interpreted as medium. However, for the longer term, this recommendation lacks sufficient support, and it appears that there is a brand‐related effect.

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4 DISCUSSION

4.1 Summary of key findings

This systematic review provides a comprehensive synthesis of findings from studies comparing the effects of a manual CA‐TB compared to a traditional FT‐TB in terms of plaque removal and parameters related to gingival health. The review examined plaque, bleeding, and gingival index scores to evaluate the efficacy differences between the two toothbrush configurations. Descriptive and meta‐analyses were conducted to analyse the data presented in the included studies.

A CA‐TB offered greater plaque reduction than an FT‐TB in a majority of the studies. However, no significant difference was observed in the majority of studies with regard to gingival index scores or bleeding scores. The meta‐analysis showed a statistically significant standard mean difference in incremental changes between pre‐ and post‐brushing plaque scores in short‐term studies for full mouth and at approximal and gingival sites. The meta‐analysis for longer‐term plaque scores, bleeding scores, and gingival index scores presented no statistically significant standard mean difference between CA‐TBs and FT‐TBs on end scores of plaque.

4.2 Other literature reviews

The present study's findings are supported by a systematic review evaluating the single‐use efficacy of manual toothbrushes, indicating that CA‐TBs are 12%–15% more effective in plaque removal than FT‐TBs. A further literature review demonstrated a difference in favour of the CA toothbrush when compared to 15 different manual toothbrushes, including various designs. However, different toothbrush designs were not compared directly in these studies.

4.3 Study quality

The quality of a systematic review depends on the quality of the included studies, including their methodology, validity, and risk of bias. A recent systematic review introduced five ethical aspects into its risk of bias assessment, including reported funding or a declared (or absent) COI. Although reporting ethical aspects is not always essential for a trial, the Consolidated Standards of Reporting Trials (CONSORT) statement recommends that factors such as the study registration, protocol, funding, and approval by an institutional ethical review board are reported. The International Committee on Medical Journal Editors has prepared a form for disclosing COIs and financial and non‐financial relationships and activities. This disclosure is now standard when a manuscript is submitted to a scientific journal. Hence, it seems a judicious choice to include ethical aspects as part of the quality assessment in a systematic review. Details of the ethical aspects of the present review are presented in Appendix S2. While most ethical aspects are addressed in the included studies, clinical trial registration is an aspect that requires attention in future studies. Clinical trials are conducted to benefit patients and, when done correctly, contribute to the public domain of evidence. However, outcomes are sometimes not reported because trials may be terminated due to negative or inconclusive findings. In this regard, registering a clinical trial improves transparency, and the availability of accurate reporting increases reliability, utility, and the impact of research.

4.4 Funding

Five of the eight studies included in this systematic review (I, II, IV–VI), , , , disclosed that the authors had affiliations with or received funding from the manufacturers of the studied toothbrushes. Research groups are increasingly reliant on external funding for their work. This reliance has raised concerns worldwide about funding bias, such as the tendency for the results of studies to favour the interests of the financial sponsor. Ridker and Torres analysed the relationship between funding source and reporting of favourable findings in randomized trials of cardiovascular diseases. They found that trials funded by profit‐making organizations (manufacturers of pharmaceuticals or medical devices) were more likely to report favourable findings than those funded by non‐profit organizations. In contrast, Oomens et al. found no significant association between funding and a higher likelihood of a favourable result in randomized controlled trials (RCTs) in oral and maxillofacial surgery. Furthermore, the authors concluded that there was no influence of the risk of bias on their main outcome, and better‐reported bias‐reducing procedures did not lead to more favourable outcomes of RCTs. Funded trials did tend to be better organized and had a lower risk of bias. Medical devices, including oral self‐care products, will primarily be studied or funded by the industry as they do not attract the interest of public domain grants, although they are relevant for dental clinics, providing evidence‐based recommendations.

4.5 In vitro studies

The present systematic review only considers clinical trials. In vitro studies have shown that CA‐TBs are more effective than FT‐TBs in terms of interproximal access., , , , In a study comparing various CA‐TBs, including four different Elmex CA‐TBs, an Oral B CA‐TB, and an ADA FT‐TB, significant differences in plaque removal efficacy were observed. The Elmex CA‐TBs demonstrated significantly higher plaque removal efficacy on interproximal sites and distal tooth surfaces in vitro compared to the other toothbrushes. Other studies have also demonstrated a greater efficacy of CA‐TBs in cleaning posterior surfaces and gingival margin areas. The in vivo results in the present systematic review substantiate these findings.

4.6 CA toothbrushes

One of the strategies to control the dental plaque biofilm structure involves removing the matrix‐enclosed microbial microcolonies by using shear (transversal) forces as induced by toothbrush bristles that cope with the adhesion forces without damaging the cleaning material surface, meaning the mechanical biofilm removal from the surface. To maximize this force, it is essential to select the ideal angle that ensures the normal force remains at least as effective as it would be in the case of a zero angle. A filament angle of about 16° was found to maximize shear force, while keeping the normal force almost constant compared to similar brush heads with straight filaments.

Penetration depth into approximal areas is another essential factor in cleaning dental surfaces. To better understand how toothbrush bristles interact with the tooth surface, especially in the proximal area, laboratory methods using robotic techniques were developed. Researchers found that the point of greatest interproximal penetration occurs when the direction of brushing changes so that bristles sweep across the tooth surface into the interproximal space, moving down and back up the adjoining proximal surface. With conventional vertical bristles, this phenomenon is limited because only a few bristles are correctly positioned at the interproximal junction when the brush changes direction. The CA‐TB was developed to address this limitation. The bristles are angled in both directions, which allows them to penetrate, lift, and sweep plaque away on both forward and backward strokes. This provides a more effective cleaning action than conventional vertical bristles. The tuft arrays are also designed to minimize bristle‐to‐bristle interference, maximize contact with the tooth surface, and enhance penetration into proximal spaces to remove supragingival plaque.,

In this systematic review, eight comparisons specifically evaluated approximal plaque reduction, of which seven showed that CA‐TBs were more effective than FT‐TBs (Appendix S11). The CA‐TB design has also been applied in combination with oscillating‐rotating powered toothbrushes. As this movement is not a ‘back and forth’ sweeping motion, the advantage of the CA design needs further evaluation, with particular attention paid to approximal penetration.

The duration of toothbrushing is likely to be an important determinant of plaque removal in the general population., , Two minutes of twice‐daily brushing is the standard expert advice from dental care professionals, dental care organizations, and the oral hygiene industry. The study by Terézhalmy et al. (2008) was excluded because the brushing duration in their study differed between the CA‐TB (1 min) and the FT‐TB (2 min). Their results can be interpreted in two ways. On the one hand, they suggest that brushing with the CA‐TB requires less time to be as effective as the FT‐TB, which could be highly beneficial as people only brush for approximately half the recommended 2 min on average. On the other hand, it is possible that the difference between the CA‐TB and FT‐TB levels out when brushing for longer periods.

4.7 Short‐ versus longer‐term studies

Five of the comparisons included in the analysis were short‐term period studies assessing the efficacy of a single brushing exercise (I–III)., , All the included studies showed a reduction in plaque within each group, although significant levels were not consistently reported. Notably, all the short‐term studies demonstrated numerical greater plaque reduction in the CA‐TB group. Since the brushing procedure was similar in CA‐TB and FT‐TB groups, the observed difference is probably attributable to the brush head design.

The study design that evaluates a single brushing action provides an assessment under controlled conditions in which all participants comply with the use of the device to which they are randomly assigned. Although the design is clearly restricted to an instant evaluation when data indicate that a specific toothbrush shows a greater potential in reducing plaque scores, it can be supposed that it offers improved plaque control over time. Consequently, it may be assumed it also has longer‐term benefits for gingival health. However, shorter‐term studies cannot substitute longer‐duration trials conducted under actual home‐use conditions. These extended studies, being more naturalistic, offer representative assessments of real‐world home usage.,

It has been recommended that longer‐term studies are required for measurements of gingival inflammation parameters, such as bleeding on probing (BOP) and gingival index (GI). Therefore, the present review included studies with a minimum study duration of 4 weeks, for longer‐term assessment. This is in accordance with the American Dental Association (ADA)'s guidelines for toothbrush Seal of Acceptance, which require studies to last at least 30 days. For this review, six comparisons emerged from longer‐term studies regarding gingival index scores, half of them demonstrating a beneficial effect for CA‐TB in the descriptive analysis (Table 3), and they also apply to the two comparisons evaluating the bleeding index. However, the meta‐analysis of longer‐term studies on gingival index scores found no statistically significant SMD between CA‐TBs and FT‐TBs. On the other hand, sub‐analysis by toothbrush brand showed a significant SMD in favour of both brands of CA‐TB.

Regarding plaque scores, the alignment of data emerging from short and longer‐term studies of CA‐TBs has been established in previous publications., In contrast to this data, our descriptive analysis showed no consistent alignment between short‐ and longer‐term outcomes. Where all the short‐term studies showed a statistically significant difference in favour of the CA‐TB in plaque scores, only half the comparisons in the longer‐term studies derived similar results, while the other half found no difference. It is worth mentioning that all three studies with the E/CA‐TBs displayed statistically significant differences from FT‐TBs, while the three studies with the OB/CA‐TBs did not. This finding might be attributable to a brand effect. Hence, it was justified to perform a subgroup meta‐analysis of different brands.

For the longer‐term studies, the Elmex® subgroup favoured the CA‐TB, while the Oral‐B subgroup studies favoured the FT‐TB. An explanation for this phenomenon could be that in the E/CA‐TB studies, the baseline scores show a significant skew towards the CA‐TB, whereas in the OB/CA‐TB studies, the skew is towards the FT‐TB. These baseline differences may have confounded the end results, making it difficult to determine the true effect of the intervention.

Another possible explanation for the difference in E/CA‐TB and OB/CA‐TB longer‐term studies could be the varying changes in filament stiffness and wear over time. To be effective, a filament must be sufficiently stiff to exert enough pressure (shear force) to remove plaque effectively. Kreifeldt et al. studied the wear of toothbrush filaments and found that new brushes were more effective at removing plaque than worn brushes. Studies also indicate that toothbrush wear is greatest within the first month, which is in line with the duration of the included longer‐term studies. Plaque removal was found to be better when there was less measurable wear. Theoretically, if OB/CA‐TB filaments exhibit more wear than the E/CA‐TB filaments, this would help to explain the observed findings. To investigate this and other possible differences between the two brands, a head‐to‐head comparison of different CA‐TBs from different brands is needed. The Hawthorne effect should be considered in future research, wherein people modify their behaviour due to being under observation, potentially inflating outcomes artificially. In the short‐term study, participants may have brushed more effectively using the experimental toothbrush due to awareness of evaluation, possibly yielding better results. However, in the long‐term study, familiarity might have normalized brushing behaviour with the experimental toothbrush, evening out the results. Counteracting the Hawthorne effect involves participant blinding, though this is impossible in toothbrush comparisons as differences are easily perceived.

4.8 Limitations and recommendations

  1. This systematic review is limited by the number and heterogeneity of the included studies. The meta‐analysis conducted was imprecise due to the small pool of data.

  2. Only publications written in English were included in this review. This language requirement may have introduced a language bias, although its impact is probably minimal given the predominance of English publications in recent decades.

  3. Ensuring participant blinding in clinical trials that compare different toothbrushes poses challenges, as participants can readily observe and experience the differences between the toothbrushes. This difficulty in blinding also applies when comparing the CA‐TB to the FT‐TB.

  4. According to the ADA guidelines (bron) on toothbrushes, the safety assessments should be continued for a total of 90 days. None of the included studies reported on this.

  5. There was insufficient data available to perform a meta‐analysis of the incremental differences. Further data would have addressed the observed baseline score disparities.

5 CONCLUSION

Within the limitations of the present study, short‐term evaluations, as assessed by various plaque indices, show a weak certainty for the cross‐angled toothbrush over the flat‐trim toothbrush. However, based on longer‐term evaluations, there is insufficient evidence to support this finding due to inconsistent analysis outcomes.

6 CLINICAL RELEVANCE

6.1 Scientific rationale for the study

Toothbrushing is widely recognized as the most effective method of dental plaque removal and the prevention of periodontal diseases. However, to date, no systematic review has been conducted to investigate the impact of manual toothbrushes (MTBs) with cross‐angled bristle tufts (CA) versus those with flat trim (FT) configurations on plaque scores and parameters of gingival health in adult patients.

6.2 Principal findings

This systematic review demonstrated a weak certainty for a very small effect in favour of the CA‐TB compared to the FT‐TB in the short term. This was not corroborated by longer‐term studies. As a result, the clinical significance of the differences between these two types of toothbrushes remains uncertain.

6.3 Practical implications

Given the weak certainty for a very small effect in favour of CA‐TBs over FT‐TBs, as demonstrated by the systematic review, and the uncertain clinical relevance of this difference, it appears that individual patient preferences, comfort, and compliance are factors to consider when making toothbrush type recommendations to optimize oral hygiene practices and promote patient satisfaction.

AUTHOR CONTRIBUTIONS

All authors approved the final version of this manuscript before submission and agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work were appropriately addressed and resolved. TMJAT: contributed to the design, search and selection, analysis and interpretation, and drafted the manuscript. GAW: contributed to the conception, design, analysis and interpretation, and critically revised the manuscript. SS: contributed to the design, analysis and interpretation, and drafted the preliminary manuscript. DES: contributed to conception and design, search and selection, analysis and interpretation, and critically revised the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no conflicts of interest. Slot and van der Weijden have previously received either external advisor fees, lecturer fees or research grants from toothbrush manufacturers. Those manufacturers included Colgate, Dentaid, GABA, Lactona, Oral‐B, Procter & Gamble, Philips, Sara Lee, Sunstar, Waterpik and Unilever. Van der Weijden has formerly received two unrestricted educational grants from Procter & Gamble Worldwide Clinical Investigations—Oral Care.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the support of Joost Bouwman, the head librarian of the ACTA; Joyce Baert, Procter & Gamble Benelux; Stephen M. Siegel from the Journal of Clinical Dentistry; and Dr. Julie Grender, a research fellow statistician at Procter & Gamble, who helped retrieve full‐text papers and data. The authors express their sincere gratitude to Parinaz Mohammadi and Christian A. Schneider for their help in preparing this manuscript.

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