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ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 275-278

A study to compare the efficacy of three different chemical agents as toothbrush disinfectant: A triple blind study


Department of Public Health Dentistry, I.T.S Dental College and Hospital, Greater Noida, Uttar Pradesh, India

Date of Submission30-Apr-2018
Date of Decision12-Oct-2019
Date of Acceptance25-Oct-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
Dr. Bhuvandeep Gupta
Department of Public Health Dentistry, I.T.S Dental College, Greater Noida, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_95_18

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  Abstract 


Background: Toothbrushes are used as an adjunct for mechanical plaque control to improve the oral health and hygiene. However, toothbrushes are an easy source of contamination by the microorganisms. Rinsing with plain tap water may reduce this microbial load, but complete elimination is not possible. Aim: The study aimed to compare the efficacy of three different chemical agents as toothbrush disinfectant. Materials and Methods: A triple-blind randomized controlled trial was conducted in a dental institute. Forty volunteers were divided into three experimental groups and one control group (n = 10). (Group A: 0.2% chlorhexidine; Group B: distilled water; Group C: Listerine; and Group D: 2% sodium hypochlorite). The participants were instructed to brush their teeth using toothbrushes with standard bristles and then disinfect their toothbrushes according to instructed methods. Bacterial decontamination of toothbrushes was measured by calculating colony-forming units (CFUs) of Streptococcus mutans, Staphylococcus, Lactobacillus rhamnosus, and Escherichia coli. Data were statistically analyzed using the SPSS software package for Windows (version 15.0, SPSS Inc., Chicago, IL, USA). Means, standard deviations, and for data of each microorganism after disinfection with different methods were calculated with descriptive statistics. The Bonferroni test was performed for post hoc analysis. A P value of 0.05 was considered as the level of statistical significance. Results: Means were calculated for the CFU in all the groups; Group D (2% sodium hypochlorite) was found to have highest mean reduction for all the microorganisms followed by Group C (Listerine), Group A (0.12% chlorhexidine), and Group B (distilled water) (control group). Conclusion: All the methods tested were effective in reducing the bacterial count of S. mutans, Staphylococcus, L. rhamnosus, and E. coli. However, the most effective method was NaOCl (2%) followed by Listerine, chlorhexidine, and water.

Keywords: Chlorhexidine, Listerine, sodium hypochlorite, toothbrush


How to cite this article:
Nissar I, Gupta B, Gupta R, Sharma A, Raina K, Kotia P. A study to compare the efficacy of three different chemical agents as toothbrush disinfectant: A triple blind study. J Indian Assoc Public Health Dent 2019;17:275-8

How to cite this URL:
Nissar I, Gupta B, Gupta R, Sharma A, Raina K, Kotia P. A study to compare the efficacy of three different chemical agents as toothbrush disinfectant: A triple blind study. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2020 Apr 2];17:275-8. Available from: http://www.jiaphd.org/text.asp?2019/17/4/275/272793




  Introduction Top


The oral cavity is the mirror of our systemic health. The maintenance of oral hygiene is as important as maintaining general health. There have been many references of using oral hygiene aids for maintaining oral health. It was found that oral hygiene was in practice as early as 3000 B.C. by the Sumerians. The medical works of ancient India suggest that the CharkaSamhita also has numerous descriptions of tooth brushing and oral hygiene. The Arabians recommended rubbing teeth with powder of gull nut and pepper. The Chinese were among the earliest people to use the Chew stick made of plant limbs or roots with one end beaten into a soft fibrous condition used for scrubbing and brushing the teeth. The bristled toothbrush appeared about the year 1600 in China. In 1938, brushes were made of nylon bristles thus evolving into a variety of form and shape.[1] Toothbrushes are used as an adjunct for mechanical plaque control to improve oral health and hygiene. However, toothbrushes are an easy source of contamination by microorganisms. These microorganisms may originate not only from the oral cavity but also from the environment where the toothbrushes are stored. Within 2 days of first usage, toothbrushes are heavily infected with potentially disease-producing bacteria, viruses, and fungi.[2] Rinsing with plain tap water may reduce this microbial load, but complete elimination is not possible.[3] Contaminated toothbrushes also play an important role in many oral and systemic diseases, including septicemia and gastrointestinal, cardiovascular, respiratory, and renal problems.[4] Toothbrushes are frequently stored in the bathroom or close to the toilet and sink which may also expose them to enteric bacteria dispersed by aerosols.[5] It was reported that when the patients change their toothbrush during an oral disease, they noticed that there is a decrease in the symptom of disease. The American Dental Association recommends that toothbrush should be changed every 3 months.[6] The role of toothbrushes in maintaining oral hygiene and the prevention of dental caries and periodontal disease has been widely researched and discussed. However, little attention has been paid to the importance of toothbrush disinfection and the choice of an ideal disinfectant. Therefore, this study was conducted to compare the efficacy of three different chemical agents as toothbrush disinfectant.


  Materials and Methods Top


A randomized controlled triple-blind study was conducted to compare the efficacy of three different chemical agents used as toothbrush disinfectant. The study was conducted over a period of 1 week in a dental institution in 2017. The ethical clearance was obtained from the Institutional Review Board for the study. All the participants were explained about the aim of the study, and written informed consent was obtained from them [Figure 1].
Figure 1: Flow chart for study protocol

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The sample size was calculated using the following formula:



where “n” is sample size, “σ” is standard deviation (SD), “Φ” is the normal distribution, “Φ −1” is the standard normal quantile function, “α” is Type I error, “τ” is the number of comparisons to be made and “β” is Type II error.

Taking mean as 200 and 250 for the two groups and SD as 50 and number of comparisons to be made as 6 because there were four groups, the total sample size comes out to be 38 which has been increased to 40 at 80% power and 5% level of significance.

A total of 100 final-year students with a mean age of 22.9 years were available to be the part of the study. On the basis of the inclusion and exclusion criteria, forty students of 100 were selected to be the part of the study.

Inclusion criteria

The inclusion criteria were as follows:

  1. Students who have at least 24 caries-free teeth
  2. Healthy gingiva
  3. No systemic or oral mucosal diseases.


Exclusion criteria

The exclusion criteria were as follows:

  1. Pregnant or lactating mothers
  2. Smokers
  3. If they had used any antibiotic within the past 3 months.


These forty participants were further divided into four groups consisting of ten participants in each group by simple random sampling using the lottery method.

The study participants were randomly divided into three experimental groups and one control group (n = 10): Group A: chlorhexidine 0.12%; Group B: distilled water; Group C: Listerine mouthwash; and Group D: sodium hypochlorite 2%.

The study participants were instructed to brush their teeth twice a day (morning and night) for 7 days using the toothbrush provide to them (Colgate Plus toothbrush with standard softbristles, a vented custom container) and a toothpaste (Colgate Total Toothpaste, Colgate Palmolive Company). They were also instructed to rinse their toothbrush under running tap water until visibly clean and then place it in the sterile container provided with 20 ml of the disinfectant for 20 min. The disinfectants were nonirritant and palatable in taste. The toothbrushes were then rinsed under running tap water for 30 s before the next use. Each participant was provided with identical bottles containing the disinfectant solution and sterile container which was coded by investigator B as Group A, B, C, and D to maintain blinding of study participants and principal investigator. After disinfection and rinsing the toothbrushes, the participants were instructed to store their toothbrush in the provided vented custom container, which allowed air circulation while avoiding the external contamination.

After 7 days, participants were asked to return their toothbrushes to the researcher in the vented custom containers, after placing in disposable sterile plastic pouches provided to them at the time of initiation of the study. The toothbrushes were then sent to the laboratory immediately (Arbro Laboratories, Delhi). The toothbrushes were examined for bacterial contamination after 7 days of use between the experimental group and control group. The contamination of toothbrush was measured by immersing and incubating the brushes in tubes containing 5 ml of phosphate-buffered saline solution (PBS, pH 7.2) at 37°C under anaerobic conditions for 48 h. After vortexing vigorously for 1 min, all tubes were diluted to 10− 2 and 10− 3. Next, 25-μl aliquots of the specimens were seeded onto brain–heart infusion agar (Merck, Darmstadt, Germany) for the isolation of Staphylococcus aureus and  Escherichia More Details coli, tryptone, yeast extract, cystine agar (Merck) for Streptococcus mutans, and de Man, Rogosa and Sharpe agar (Merck) for Lactobacillus rhamnosus. Specimens were incubated and the grown colonies were counted. The number of colonies was calculated according to the dilution ratio and defined as the number of colony-forming units (CFUs) per milliliter.

Data were statistically analyzed using the SPSS software package for Windows (version 15.0, SPSS Inc., Chicago, IL, USA). Means, SDs, and for data of each microorganism after disinfection with different methods were calculated with descriptive statistics. A Bonferroni test was performed for post hoc analysis. A P value of 0.05 was considered as the level of statistical significance.


  Results Top


Mean CFUs/ml were calculated for all the groups. Group D (2% sodium hypochlorite) was found to have the highest mean for all the microorganisms and was found to be the most effective disinfectant followed by Listerine, 0.12% chlorhexidine, and distilled water (control), respectively, considering the number of all types of bacteria which was found to be statistically significant using the one-way ANOVA [Table 1]. When the efficacy of different disinfectant groups was checked for different microorganisms using post hoc analysis, for S. aureus group, there was no statistically significant difference found between the groups except A with D, B with C, and D. Similarly for S. mutans, Group D had a statistically significant difference when compared to Group A, B, and C. When analysis for L. rhamnosus was done, Group B showed a statistically significant difference with Group A, C, and D, and finally, when the comparison was done for E. coli, Group A showed a statistically significant difference from C and D and Group B also had a statistically significant difference from Group C and D [Table 2].
Table 1: Mean colony-forming units/ml according to the type of bacteria

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Table 2: Post hoc analysis between groups

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  Discussion Top


In the present study, different chemical antimicrobial agents were used for toothbrush disinfection due to their accessibility, cost-effectiveness, and potential antibacterial effects. The result of our study showed NaOCl to be most effective method for toothbrush disinfection which is in accordance with the study done by Basman et al.[3] NaoCl is widely used as a root canal irrigant in endodontic because of its broad antimicrobial activity. The cytotoxic properties of 2%–2.5%NaoCl do not appear during short-term exposure and no genotoxic effect has been reported for host tissue.[7] Bhat et al.[1] also investigated the microbial contamination of toothbrushes and their decontamination and suggested that 0.2% NaoCl reduces the count of microorganisms. Mobin et al.[8] investigated fungal contamination in toothbrushes and suggested that submersion in 2% NaoCl for 3–5 min is an effective and method to disinfect a toothbrush. Nelson-Filho et al.[9] investigated microbial contamination of toothbrushes and concluded that NaoCl and chlorhexidine are the most effective method for toothbrush disinfection. da Silva et al.[10] investigated the effectiveness of different solutions for disinfecting acrylic resin specimens contaminated with Candida albicans, S. mutans, S. aureus, E. coli, and Bacillus subtilis. They found 1% NaoCl to be the best antimicrobial agent against the tested microorganisms. This result was supported by Salvia et al.[11]

In contrast, Komiyama et al.[12] found chlorhexidine as an effective method in toothbrush disinfection. Hamal et al.,[13] in their study, also found chlorhexidine effective method in toothbrush disinfection. However, in our study, chlorhexidine was found to be the third-most effective method of disinfection after sodium hypochlorite and Listerine. Mouthwashes containing essential oils and alcohol, such as Listerine, have the best antibiofilm activity and could be used to prevent plaque formation after periodontal treatment. Erriu et al.[14] used Listerine for 20 min to disinfect toothbrushes and reported that its effectiveness was lower than that of mouthwashes with chlorhexidine. Konidala et al.[2] investigated the efficacy of various disinfectants on microbially contaminated toothbrushes due to brushing and concluded that Listerine to be the most effective method for disinfection of toothbrushes. In contrast, the present study found Listerine to be more effective than chlorhexidine. Furthermore, Listerine was the second-most effective chemical agent against all tested bacteria, after 2% NaoCl. Further studies determining the cytotoxic and genotoxic effect of NaOCl including its biocompatibility are needed to increase the awareness among clinicians and general public.


  Conclusion Top


All the methods tested were effective to reduce the bacterial count of S. mutans, S. aureus. L. rhamnosus, and E. coli. However, the most effective method was NaOCl (2%) followed by Listerine, chlorhexidine, and water.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhat SS, Hegde KS, George RM. Microbial contamination of tooth brushes and their decontamination. J Indian Soc Pedod Prev Dent 2003;21:108-12.  Back to cited text no. 1
[PUBMED]    
2.
Konidala U, Nuvvula S, Mohapatra A, Nirmala SV. Efficacy of various disinfectants on microbially contaminated toothbrushes due to brushing. Contemp Clin Dent 2011;2:302-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Basman A, Peker I, Akca G, Alkurt MT, Sarikir C, Celik I. Evaluation of toothbrush disinfection via different methods. Braz Oral Res 2016;30. pii: S1806-83242016000100203.  Back to cited text no. 3
    
4.
Nascimento AP, Watanabe E, Ito IY. Toothbrush contamination by Candida spp. and efficacy of mouthrinse spray for their disinfection. Mycopathologia 2010;169:133-8.  Back to cited text no. 4
    
5.
Taji SS, Rogers AH. ADRF trebitsch scholarship. The microbial contamination of toothbrushes. A pilot study. Aust Dent J 1998;43:128-30.  Back to cited text no. 5
    
6.
American Dental Association. ADA Positions, Policies and Statements. Toothbrush Care: cleaning, Storage, and Replacement. American Dental Association; 2005. Available from: http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-toothbrush-care-cleaning-storage. [Last accessed on 2011 Apr 21].  Back to cited text no. 6
    
7.
Aubut V, Pommel L, Verhille B, Orsière T, Garcia S, About I, et al. Biological properties of a neutralized 2.5% sodium hypochlorite solution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e120-5.  Back to cited text no. 7
    
8.
Mobin M, Borba Cde M, Filho CA, Tapety FI, Noleto Ide M, Teles JB. Analysis of fungal contamination and disinfection of toothbrushes. Acta Odontol Latinoam 2011;24:86-91.  Back to cited text no. 8
    
9.
Nelson-Filho P, Pereira MS, De Rossi A, da Silva RA, de Mesquita KS, de Queiroz AM, et al. Children's toothbrush contamination in day-care centers: How to solve this problem? Clin Oral Investig 2014;18:1969-74.  Back to cited text no. 9
    
10.
da Silva FC, Kimpara ET, Mancini MN, Balducci I, Jorge AO, Koga-Ito CY. Effectiveness of six different disinfectants on removing five microbial species and effects on the topographic characteristics of acrylic resin. J Prosthodont 2008;17:627-33.  Back to cited text no. 10
    
11.
Salvia AC, Matilde Fdos S, Rosa FC, Kimpara ET, Jorge AO, Balducci I, et al. Disinfection protocols to prevent cross-contamination between dental offices and prosthetic laboratories. J Infect Public Health 2013;6:377-82.  Back to cited text no. 11
    
12.
Komiyama EY, Back-Brito GN, Balducci I, Koga-Ito CY. Evaluation of alternative methods for the disinfection of toothbrushes. Braz Oral Res 2010;24:28-33.  Back to cited text no. 12
    
13.
Hamal JD, Hensley DM, Maller SC, Palazzolo DJ, Vandewalle KS. An in vitro comparison of antimicrobial toothbrushes. Gen Dent 2014;62:e24-7.  Back to cited text no. 13
    
14.
Erriu M, Pili FM, Tuveri E, Pigliacampo D, Scano A, Montaldo C, et al. Oil essential mouthwashes antibacterial activity against Aggregatibacter actinomycetemcomitans: A comparison between antibiofilm and antiplanktonic effects. Int J Dent 2013;2013:11-4.  Back to cited text no. 14
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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