Sir, I read with interest the recently published paper on toothbrushing (BDJ 2014; 217: E5). However, I was disappointed that the authors were rather selective in their literature review and somewhat failed to convey the well-documented evolution in toothbrush technology and toothbrushing methods that has occurred over the past 20 years.

In 1998, a European Workshop on Mechanical Plaque Control published a comprehensive review of methods of toothbrushing1 and reiterated the statements from 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'.

In addition, Beals et al.3 evaluated the brushing techniques of adults in three separate geographic regions using video recordings and reported that in an average brushing time of 46 seconds, a combination of three basic movements was used, with the horizontal scrub being employed nearly 70% of the time – in line with other published studies.4

Based on the available research Löe concluded in his Millennium Lecture at EuroPerio in 20005 that in order to enhance plaque control the time had come to consider new toothbrush technologies and ways to simplify oral hygiene procedures. Towards this end, the cross-action manual toothbrush was developed with the intention of designing a toothbrush which could enhance plaque removal when used with a horizontal natural brushing technique. A 16° bristle angle was demonstrated to improve interproximal penetration, resulting in a significant increase in plaque removal.

A recent systematic review on the efficacy of manual toothbrushes by Slot et al. reported that 'clinical studies have consistently demonstrated that a brush with an angled bristle tuft configuration is significantly more effective'.6 Contemporary power toothbrushes are proving to be even more efficient in removing plaque, specifically brushes with an oscillating rotating head, which have been consistently shown in a Cochrane systematic review7 and two subsequent updates8,9 to be more effective than manual brushes in removing plaque and reducing gingivitis in both the short- and long-term.