Sir, in response to the letter by L. Mackenzie (BDJ 2014; 217: 612–613), Toothbrushing evolution, I would like to address the points he raised about our paper (BDJ 2014; 217: E5). We acknowledge the conclusions of the 1998 European Workshop on Mechanical Plaque Control Review1 reiterating the statement in the 1986 World Workshop2 that 'improvement in oral hygiene is not as dependent upon the development of better brushing methods as upon improved performance by the persons using any one of the accepted methods'. Indeed, Levine and Stillman-Lowe in the BDJ book The scientific basis of oral health education³ agree with us that 'The precise technique is less important than the result' and that 'a gentle scrub technique is effective for most people and is easy to teach and readily accepted'. Our study indicated, however, that this statement did not appear to have influenced advice on toothbrushing method provided by professional sources.

The Beals et al. paper4 quoted by Mackenzie is about efficacy of a toothbrush with a special design, whilst the systematic reviews5,6,7 quoted concern powered brushing. Whilst we know that different toothbrush designs – including powered brushes – may have an effect on plaque control, the focus of our study was on standard manual brushes which the vast majority of the global population use. Powered toothbrushes or those of special design may cost several times what a manual brush may cost, and are thus not affordable by a large section of society.

It is prudent to note our paper aimed not to determine a best toothbrushing method, but to assess the variation in the method recommended. The literature review was selective in addressing stated aims we hoped to achieve.