The Circular Method of Brushing: What it is and how it transformed my patients' health

When I started dental hygiene, it was 1976—before OSHA, masks, gloves, and gowns. White caps and bare hands were standard uniforms. The soft nylon bristle had just been introduced as the most modern toothbrush. The .007 mil bristle allowed for concentration on the gingival margins, where the bulk of the plaque accumulates.

Before I returned to school for my bachelor’s, I was working full time, five days a week, eight to nine hours a day, and a patient every hour. (Ideal, right?) I was noticing constant ailments: strep throat, flu, and “cold of the month” as I called it. I was convinced that if I could reduce the amount of plaque around the patient’s teeth, that it would cut the transmission of the common cold and flu virus significantly. It would also reduce the odor in the subway cars and make traveling around NYC a whole lot nicer.

I noticed that the few patients to whom I recommended this technique, which I called the Circular Method of Brushing, returned at the following recall appointment almost calculus free and minimal gingival inflammation, bleeding and plaque.

This is when I knew I should follow my patients and record the effects. I had a hypothesis that the reduction of the bacterial and viral plaque accumulation at the gingival margin reduces the bacterial and viral levels that are transmitted through the oral-plural route. (1) Interestingly, today’s research includes the transmission of bacterial/viral material directly into the bloodstream through the inflamed gingival tissue.

I am grateful for the establishment of OSHA to assure safety for health-care providers. Interestingly, perhaps if OSHA had been established earlier, I might not have had the intense need to reduce marginal bacterial plaque. I did learn that sucking on salted pistachio nuts hourly helped prevent and alleviate strep throat. It was far better to allow the salt to kill the bacteria rather than to be taking erythromycin constantly.

I was advised to make films to document my hypothesis since it would be five years before the study was completed. You can watch them below. All the while I was working part time and going to school part time. As­ chairperson of the committee for publicity for the First District Dental Hygiene Society of New York, I dedicated the film to this organization. I found two part time positions to accommodate a school schedule. I didn’t know which office I would get the five years, necessary for the study.

Every patient was evaluated according to need using gingival and calculus indices. (2) Everyone with granular gingival inflammation and beginning recession was put on the Circular Method. Everyone else maintained their current home care routine. I followed 600 patients for five years in two offices.

The observations were the most exciting.

I started to notice immediate changes after the first recall. The most astounding noticeable change was in the physical appearance of my patients, a lipstick effect. This was the most unexpected and marked difference. I did expect a more thorough brushing would result in reduced gingival inflammation and depositing.

What is the circular method, anyway?

Place the soft bristle toothbrush, electronic or handheld, on the gingiva above the tooth, perpendicularly, without angling it, and rotating it in a small circular motion covering the gingival margins and the teeth. By brushing the gingiva, the sulcular areas the floss cannot reach are cleaned. Using gentle pressure, the bristles can remove the plaque. Chronic gingivitis will be cleared by the following recall. The circular movement allows the bristles to clean around difficult anatomy without added abrasion. Teeth are not flat, paper thin, or a picket fence, and there are so many areas that need to be cleaned. Keeping the gums clean and healthy keeps the teeth healthy too. This will make recall appointments easier for the patient and the hygienist. I am awful and make my patients demonstrate the technique to make sure they get the difference in motion and focus. Some get it right off, some need help getting the feel of the motion. If there is muscle memory, they will be able to do it without much thought. Many feel it is counterintuitive and are afraid that if they brush their gums, they will bleed. The first part of the film below demonstrates the circular method of brushing.

This method differs from Dr. Fones’ (3) in that the brush focus is concentrated on the gingival margins of each arch. Dr. Fones instructed children to brush all the teeth at once, since the dexterity of a child is limited, not concentrating small circular strokes on the upper gingival margin then the lower gingival margin. In his day the toothbrush was made of Boer’s hair, which the hairs were hollow, pointed, hard, and sharp. Today’s toothbrush is made of nylon filaments with rounded ends, thus opening a spectrum for better care. The softer nylon toothbrush lent itself well to battery power and wide public use, and public health has greatly improved.

Other gingival improvements in the study included:

Gingival clefting: When I left school in the late 1970’s, there was no known cause for gingival clefting. A high frenum attachment that was pulling on the gingival margin might have a similar appearance. However, clefting was a sign of active periodontitis and active recession. Clefting was resolved in patients using the Circular Method directed at the dentogingival margins.

Dentinal abrasion and gingival recession were halted and maintained.

Common cold and flu transmission had significantly reduced.

Brushing and the Circular Method today

Thirty years have passed since the completion of my five-year double-blind study on the circular method of brushing. The journey, process, and conclusions were uplifting.

Today, I still see clefting and abrasion. The patient is directed to use sonic and spin brushes by placing the brush on the tooth surface and moving it along the teeth in the arch, not touching the gingiva, leaving the sulcus filled with plaque, continuing the process of periodontal recession. Once I explain the ability of the toothbrush to touch the gingival margins to patients, the clefting areas round off and the granular marginal inflammation had subsides by the next recall.

Using either a sonic toothbrush or spin brushes, directing the placement on the gingival margin rather that the tooth surface, and moving it in a small slow circular motion has improved benefits, including disturbing the biofilm and dislodging plaque, eliminating inflammation, reducing caries, bad breath, and common cold and flu transmission.

It is well understood that inflammation can allow for different diseases to directly enter the bloodstream (4). Early in my career, the threat of bacterial endocarditis was prominent and associated with dental check-ups and prophylaxis. (5) If this can happen during a simple cleaning, why can’t it happen with a good scrubbing of the teeth and slight gingival bleeding? Every day new studies showed that gingival inflammation can cause plaques to build and enter into the blood stream, building plaques within the arterial walls, causing heart disease. (6) Now there is may be a connection to Alzheimer’s and other diseases. (7)

I am always delighted to see new patients, particularly their brushing habits. Some are using the Circular Method, some with an electronic toothbrush, however most are still afraid to touch the gingiva with a toothbrush. The most noticeable gingival issues I see are marginal inflammation, bleeding, granular gingiva, and puffy inflamed papilla. Inevitably the patients are using the Rolling Stroke or Stillman’s/Modified Stillman’s methods of brushing, but actually using the scrub technique. These methods do not concentrate on the gingival margins, which means plaque there remains undisturbed. Often, patients who see a bit of bleeding when brushing avoid brushing the gingival margins, also promoting gingival inflammation. However, once I switch them to a soft toothbrush, and demonstrate the method, they are able to see the difference and recalls are usually free from inflammation.

There is still a need to use a good brushing technique with the electronic toothbrushes. I have noticed with my patients that placement on the tooth and just moving the sonic brush across the arch does not reach interproximally, although aeration will kill some anaerobes, plaque is not a single layer thick, nor will it dislodge plaque in the sulcus. If the dentogingival margin is not engaged, plaque will continue to develop producing chronic gingival inflammation, recession and clefting. There are areas the floss cannot reach. The soft toothbrush, whether it is sonic, spin, or manual, must be able to reach the sulcus areas to prevent disease. All of the brushes have easy to grip handles and can be manipulated to dislodge and remove plaque, disrupt the biofilm, and aerate the gingival sulcus. I am convinced that being able to aerate the sulcus is a nice advent to gingival health.

In spite of technique of the user, I have seen wonderful changes in the health of my patients. However, with a bit of care by the user I am astonished at the ability of this new technology to change the shape of dental check-ups and dental care.

References

1. Lawrence A. Circular method of brushing. Toothsurvey website. https://toothsurvey.webs.com/.
2. Spolsky. Epidemiology of gingival and periodontal disease. In: Glickman I, Carranza F. Glickman’s Clinical Periodontology. 7^th ed. W.B. Saunders Co; 1990:324-325.
3. Lakshmi D. Brushing technique. SlideShare website. https://www.slideshare.net/lakshmi01071994/brushing-techniques-70870057. Published January 10, 2017.
4. Sauer A. How Gum Disease Could Lead to the Development of Alzheimer’s. Alzheimers.net website. https://www.alzheimers.net/gum-disease-could-lead-to-the-development-of-alzheimers/. Published February 7, 2018.
5. Windle M. Antibiotic Prophylactic Regimens for Endocarditis. Medscape website. https://emedicine.medscape.com/article/1672902-overview/. Updated February 5, 2018.
6. Gregg RH. The surprising link between periodontal disease and heart health: What dental professionals need to know. DentistryIQ website. https://www.dentistryiq.com/clinical/article/16366436/the-surprising-link-between-periodontal-disease-and-heart-health-what-dental-professionals-need-to-know. Published January 30, 2017.
7. Li X, Koltveot KM, Tronstad L, Olsen I. Systemic Diseases Caused By Oral Infection. Clin Microbiol Rev. 2000;13(4):547-558.

Audrey Lawrence Rosenberg, BS, RDH, was trained at Northwestern University Dental School. She wrote The Tooth Survival Book, ADA publication 1976, which was in print for over 10 years. She became a delegate to New York State and helped reform the root planning and scaling regulations in the late 1970s. A member of the American Academy for Oral Systemic Health, she also enjoys research and development. She designed the OptiBrusher (optibrusher.com), a full-mouth toothbrush. She currently practices in Connecticut.