The Cleanse-Massage Method

The  “Cleanse-Massage”  Method Prophylaxis

The Importance of Mouth Cleanliness is Emphasized in


By  Leo Albert, D. D. S.

            Toothbrushing, until recently, was confined to the instinctive propensity to scrub the teeth. The unlearned millions use some form of the horizontal or vertical stroke. Many of these manners of using the brush have demonstrated their irrationality by injuries inflicted and inadequate results. Evidently, general understanding of the toothbrush has remained crude. I believe all this accounts for the failure of the brush to do its share in maintaining dental health.

Scientific Application of Toothbrush

From these experiences of faulty brushing and from consequent rational application of ideas, scientific manipulations of the brush are being cultivated by those interested. Like everything else today, it is found that the handling of the toothbrush can have a scientific procedure –a form most suitable and intelligent for the purpose. This work having begun, is potentially open to valuable melioration.

I shall endeavor herein, to offer some of these scientific technicalities. Being that they depend upon the method of toothbrush use I have advocated, I shall first outline succintly the procedure.

The method which I have called “cleanse-massage,” has for its purpose cleaning the teeth and massaging the gums simultaneously. This is done by first placing the brush in the right position.

We shall start with the facial (labio-buccal) surface. The brush is placed asland on its side in such a manner that most of the bristle sides are on the gum and the bristle ends are solely on the teeth surfaces. The brush is less than forty-five degrees to the long axis of the teeth. The backbone of the brush is slightly raised off the soft tissue, the bristles are thus made to rest mostly on the teeth. The brush is parallel to the sagittal of the dental arch.

The next step is the movement of the brush. The bristles are kept in one position. As they rest on the teeth, this part becomes the pivot and fulcrum in the movement to follow. The handle only is moved n very short easy circles. The bristles are thus indirectly swayed in short circles, conforming to the tooth surfaces. Each bristle end, apart from adjacent bristles, has a small tooth surface over which to make its excursions. The bristle end passes over a minute surface several times, and loosens any foreign deposits clinging to the surface. All ends combined cover the entire facial surfaces of the teeth including the gingival third and a good way into the adjacent mesial and distal surfaces. While the bristle ends loosen debris from the teeth, the bristle sides are gently stimulating the gums.

In this way, both cleansing the teeth and massaging of the gums are done in one operation. It simplifies these two important functions, saves time and secures doing both of them. The lingual is done similarly excepting handle is tilted to clear the anterior teeth leaving half or less of the brush to function. The cleansing extends into the mesial and distal surfaces adjacent to the lingual surface. The occlusal action is performed on the same principle but the bristles are perpendicular to the occlusal surface. The bristle ends are at the occlusal surfaces, the backbone being farthest from the teeth.

The handle only is again moved as before, in short circles in a plane parallel to the occlusal plane. No attempt is made to move the bristles directly: the bristles are merely supported on the teeth. The bristles sway indirectly as they did facially and lingually, fitting deeply into the teeth formation and spirally scooping debris loose and outward from grooves and sulci along the angles up to the cusp formations.

Method is Simple and Plain

In practice, the steps or rules of the method simple and plain. The bristle ends are placed on teeth surfaces; the bristle sides lie on the gum, taking care that the handle is slightly off soft tissue; short light rotary movements of the handle are applied to the tissues through the bristles. These are repeated from one area to another. The occlusal operation differs only in the brush not being placed against any gum.

Type of Brush Important in Application

The technique just described demands certain requisites in the construction of the toothbrush to collaborates successfully with the method. The brush will be considered, therefore, before proceeding with the technical factors.

The handle of the brush should be straight and rigid in order to convey the movement of the hand directly and fully to the whole handle, since only the handle is motivated in this technique. Any bends would break the force to lessen the movement, and also tend to tip and slip the brush. A handle that is somewhat flexible will loss some of the applied force at the point of use.

The brush itself, for average use, should be about an inch long, three-eights wide and the height of the bristles one-half inch from the backbone. The bristles tufts or clusters should be uniform in height to secure even pressure on the tissues, to avoid obstruction to some bristle clusters by longer ones, to obviate excessive pressure to some tissue by highest clusters.

Each cluster may taper slightly at its end to allow better distribution of bristles over tooth surfaces to permit the bristles’ movement; and make the brush more accessible for cleaning. The brush should be wide enough –three rows of clusters, to cover the whole facial, lingual or occlusal surface.

As to technical factors, attention is drawn first to the exclusion of stroking from the method in favor of the indirect short rotary movement. The use of the stroke is not a good choice for several reasons. It leaves streaks of debris that are not distur.bed between bristles. Moreover, by the transitory movement of the brush in stroking, there is no control that it will clean every bit of area in passing, thus lacking in efficiency. Furthermore, stroking brings the sharp edges of the bristles in contact with the enamel surface causing abrasion; and where these edges stroke the gum, scratching and subsequent hemorrhage may result.

The sidewise position of the bristles and short rotary movements in the cleanse-massage method precludes the weakness of the stroke. The movement of each bristle end in short circles repeatedly over its area, all combine covers the entire surface of the tooth. It is done more frequently than the usual transitory stroke. Each bristle circumscribes its particular area and loosens debris fully. Holding the bristles in one area and moving it several times, acts as a good control of the operation.

The bristles, sidewise and gentle, do not abrade the hard tissues or scratch the soft tissues. The short rotary movement is also advantageous in that it has an absorbing action of the loosened debris. That is, by its whirpool movements, it sponges up more readily the debris compared to the stroke’s action of sweeping it into other areas that are often recessed.

In the cleanse-massage method, the bristles held sidewise, the ends of the bristles were used –that is the very ends of the bristles were used. This should be noticed in distinction to the edges or tip points of the bristles which are usually used in other methods. As it has been previously indicated under the short rotary movement and sidewise position, the ends of the bristles being broad and smooth, differ from the edges in not scratching tissues. Moreover, the greater surfaces of the bristle ends over the points of the edges grip the tooth surfaces much better, giving good control and consequently deftness in the manipulations. Finally the broader surfaces of the ends over the minutes surface of the edge of tip, increase the cleansing surfaces of the bristles.

Notice, there are two distinct parts to the manipulation of the brush. The first is position. The brush must be properly placed before any success can be derived from the manipulation. A wrong position can do worse –injure tissues such as bristles scratching soft tissues. Too much pressure of one area or too little on another is undesirable, for there is a lack of cleansing and stimulation in one area and excessive in another one.

Only Bristle Sides Should Touch Gums

In placing the brush, special attention is called to having the bristle ends exclusively on the teeth surfaces so that no edges are in contact with the soft tissue to possibly scratch and pierce the gingiva, causing injury and hemorrhage. Only the sides of the bristles touch the gum; the bristle sides, being smooth, obviate any scratching. At the gingival septums, the bristle ends do not disturb the soft tissue as it is recessed, the bulge of the tooth protects the soft tissues.

Furthermore, the motion in this area occupies the bristle ends mostly with the mesial and distal surfaces of the teeth. It is only after the proper placement that the second part, or the action, is ready. Movement of the handle of the brush only and in very short circles must be observed. The bristles are not permitted to be moved directly with the handle. This would create sweeping, that is, the objectionable strokes.

Another feature is the endeavor to cover entire accessible surfaces by several technicalities. The position of the brush causes the bristles in groups to have the tooth surface under treatment, the bristles fitting the shape of the tooth.

The entire length of the crown facially or lingually is coveted by the brush from the gingival to occlusal, so is the occlusal surface entirely reached from facial to lingual and mesial to distal. The rotary movement also conforms to the curved surfaces of the teeth, thus in action too the tooth is covered with the brush.

In contrast, the horizontal and vertical strokes, the sidewise vibration and the rolling movements of other methods are inclined to touch the teeth at a tangency, and do not have adequate contact to function. The toothbrush recommended for the method as I previously stated has a broad width of three rows to aid in covering an entire surface of a tooth.



Short Movement of the Handle

The short movement of the handle is an economy and encourages a greater number of revolutions in an area. At the same time the short movement discourages propensities to recede the gum. The advantage of short movement lies not so much in the short movements of the handle, but, in the indirect swaying of the bristles. The latter movements are further divided into minute movements of individual bristles. If the short movement of the handle were transmitted directly into the bristles making, in other words, a stroke, the bristle movements would make too large a movement to be safe for the gums.

The brush should be mostly supported on the teeth and to a lesser extent on the gums. In this manner, the greatest efficacy is secured for cleansing and stimulation.

The position and movement of the brush that follows all the rules allows the brush to enter both recessed parts of teeth and teeth wholly recessed, such as those in lingual version.

In children’s mouths of changing dentition, where in teeth are not fully erupted and the gum is exposed at, and reaches near, the occlusal plane, the occlusal position of the brush is best turned from the regulation position, namely, perpendicular to the occlusal plane. It is better to modify the bristle position to an oblique so that the bristle ends, sidewise, come in contact with the gums instead of the bristle tip to reduce the chances of gingival injury. The bristles in this modified position are still very capable of fitting into the occlusal formations of the teeth and clean them.

It is difficult to suggest any set rules for holding the handle with the hand. People’s dexterity vary innately and habitually. However, it may be said that the main grasp of the handle can be made with the middle, fourth and fifth fingers on one side of the handle and the pads of the palm on the other side, the handle resting in the palm. The thumb and index fingers slide forward nearer the brush to act as a guide and control.

Different parts of the mouth, right and left, upper and lower, will cause the hand to take its most naturally convenient position when the brush is placed properly on the dental structures. Outside of this, the operator may have some modified manual dexterity suitable to himself. It does not matter whatever it may be, provided the technique within the mouth is correct.

It is usually best to see what one is doing and this applies to the use of the toothbrush as well. Since it cannot be seen directly, as combing the hair, it is preferable to use a mirror at all times.

In using the toothbrush, the mouth should be opened as widely as possible with the exception of the facial and particularly the molar facial region. In these areas, when the mouth is partly closed and the muscles relaxed, more space is provided in the vestibule to apply and move the brush.

An orderly procedure is necessary to obtain completeness and efficiency. The upper jaw is best treated first so that if any debris falls to the lower jaw, it can be picked up later. One half of the jaw is completed at one time to avoid confusion of brush positions in going from one side to the other. The facial side is done, then the occlusal surfaces, and lastly the lingual sides.

It is best to start with the most posterior tooth and proceed anteriorly. In this way the posterior teeth, the greater harboring areas of debris and more vulnerable to decay due to food decompositions, are surely cleaned. It is a common occurrence for laymen to start cleaning the front teeth and end weakly or not at all on the molars.

Overlap Applications of the Brush

In passing from one area to another it is important to overlap the applications of the brush so that no gaps of untreated areas occur. Areas in which accumulations are not removed and lack stimulation over long periods, become conspicuously unhealthy. They are silent testimonies of neglected toothbrush care –that is, if natural cleansing and stimulation are absent too. Therefore, it is important that no area is overlooked even though it may seem insignificant at the time.

I am of the opinion that a goodly pressure of toothbrush application is contraindicated. I know opposite views are held. The foregoing method described, requires a gentle, easy, free movements. I shall present several reasons for this attitude.

Only Gentle Stimulation for Gums

The gums were naturally intended to receive a gentle stimulation, sufficient for  a normal circulation to transmit those essential coordinate factors of health: nutriment and removal of wastes. Excessive pressure create inflammation, plethora and hypertrophy. Tight pressure against the teeth locks or jams the bristles, preventing movement.

A free movement is necessary is cleanse-massage to secure the rotary movement and sway of the bristles. The bristles, when allowed free circular movement, meander and penetrate into all spaces of the entire tooth surfaces open to them. The gentle free movements allow adequate function, do not produce trauma and in addition make for a quicker action.

The very short circular movement and indirect gentle movement and indirect gentle movement of the bristles precludes any chance of detaching the gingivae from the teeth. When the bristles are brought excessively from tooth to gum in any direction against the parabolic curve of the marginal gingiva, horizontal, vertical or any intermediate oblique, the free gingiva is moved away from the tooth. It creates a flap, or a ledge.

This acts as a good hold for the next movement of the bristles against the gum, and the gingiva in time is ripped from its attachment. In addition to direction, the wrong movements causing gingival detachment are large movements and direct ones of the stroke.

A thorough rinsing of the mouth after using the brush is necessary to flush and remove as much as possible the loosened debris that has not come away with the brush.

As to the frequency of rotations in an area, ten times is a desirable number but it should be done at least six times to insure adequate efficiency.

The directions of the brush’s placement must be noticed and observed. Facially the long axis of the brush should be invariably parallel to the mesiodistal direction of the arch. This applies to the occlusal too. The posterior lingual surfaces would be best served by this placement but is modified as much as the handle requires tilting.

On the anterior lingual surfaces, the long axis of the brush may be even parallel to the long axis of the teeth. In difficult, exceptional places, the brush is held in any necessary angle provided the general principles of the method are obeyed. Many parts of the toothbrush can be utilized to better advantage.

It is not necessary to restrict it to the edges alone or edges and full side of the length of the brush. The width of the toe of the brush can be very conveniently used in inaccessible places, so too, the corner made by the toe width and the length of the brush.

When the interdental gingivae are normal, it is not necessary to bring the bristles of the brush between and through the teeth. The gingival attachments run high interproximally covering a good part of the proximal tooth surfaces, protecting the latter against decay. Most of this tooth surface excepting the contact point is automatically kept clean by the constant thin flow of saliva in the gingival the trough. The normal contacts keep themselves clean.

Therefore, artificial cleansing is not required in the normal case and no attempt should be made to do so as it will in time break down this natural protection. (As to the abnormal septum, I hope to give it consideration under the subject of difficult areas to clean, sometime in the future.)

Averagely it takes most people fifteen to twenty seconds to brush the teeth, ordinarily. Of course, it is a hurried, perfunctory and careless brushing. Those who are proficiently the cleanse-massage method take two to three minutes after they have become proficient. Those who are accustomed to spend fifteen seconds with the brush usually imagine they are taking several minutes, for they never time themselves. But a minute is a long time when your attention is called to it; and two or three minutes with the cleanse-massage method seems like a very long time. But two or three minutes every time for oral hygienic care during twenty-four hours a day is not too much time for such an important function.

Brush, Important Preventive Measure

Time taken with the toothbrush is well worth it for its share in preventing dental disease. As professional men we wish to prevent dental disease, of course, to protect our patients in maintaining their health and precluding suffering and restoration. Do we give enough thought, however, to preventive dentistry as a protection of the profession against practice hardships? –and as a means against entering a labyrinth of problems in treating disease and restoring function from which we cannot extricate ourselves to give patients a fraction of the service we would desire?

When tissues are preserved by preventive means, the tissue intricacies are left in contact to function at their best. Destruction makes it impossible to restore all the detailed parts and processes to equal the original conditions.

We can only give excellent service by preventive treatment –to keep dental tissues inactive to destroying agents, and more important, uphold the resisting tone of the tissues.

One of the more effective means to aid in this direction, during our present mode of living, is to institute proper technical use of the toothbrush.

In developing the technique of the foregoing factors, they have, to a good extent, been patterned on, and any future improvements should be guided by, the natural and automatic cleaning and massage of dental tissues by hard and coarse foods in mastication. This natural good effect is well demonstrated in the disease-free mouths of those people and lower animals who live on natural tough and unadulterated foods.




Choose Foods for Exercising Value

As to the proper diet mentioned, to clarify the issue, I have restricted myself to the foods detergent and exercising values.

Nutrition is another subject of great value. The proper foods such as untampered raw vegetables and fruits, coarse and hard breadstuffs, are firm and some fibrous, yet yielding without abrasion or piercing the tissues. In chewing, the greater pressure of these foods, cleaning the teeth while being masticated, is brought on the occlusal surfaces of the teeth.

As the firm fibers of food move gingivally along the sides of the teeth, they are softened by trituration and salivation so that their action on reaching the gingival mucosa is more gentle. The movement of the mandible against the maxillae, the movement of the tongue and the cheeks in mastication are in repeated small circles. The bolus ism oved around the teeth, rubbing around all those tooth formations that only are exposed to cleaning and that only need cleaning.

The manner of using the toothbrush should be similar. In the cleanse-massge method, there has been an endeavor to imitate this as much as possible. In the occlusal position, the toothbrush weight is entirely on the teeth, on the facial and lingual surfaces, the toothbrush, it will be recalled, is mainly on the teeth and during the action the fulcrum is on the teeth. The bristle ends with their greater force and end effect are against the teeth while the bristle sides are moving more gently against the mucosa. The bristle ends parallel the firmer fibers of food first crushed by teeth surfaces while the bristle sides correspond to the softened fibers of food. The short circular movements of the brush repeatedly, conforming to the curved surfaces of the teeth, simulate the repeated short circular movements of the jaw, tongue, and cheeks.

It is not to be implied that the toothbrush can extremely surrogate the natural cleansing and massage of foods. I doubt whether this will ever occur. After all the use of the toothbrush is at best an imitation. Nevertheless, intelligent use of the brush can materially supplement the inadequacy of natural cleanse-massage and when natural cleanse-massage is entirely absent, the toothbrush method described can vicariously aid.

It follows, then, cleanse-massage with the toothbrush would be most ideally used after the mastication of any food which inadequately stimulated and self-cleansed the dental structures.

Food of the modern soft variety, it should be remembered, not only lacks cleansing and massaging benefits, but worse –adheres to tooth surfaces and clogs the gingival margins. Consequently, these collections of food cause acid formation and often tooth decomposition. Moreover, the delicate foods offer the soft tissues no exercise and together with their accumulation around the gingivae often results in disease of the parodontium.

For the present at least, we must resign ourselves to the general retention of the modern soft and adulterated diet for obvious reasons. The consequence, of course, is continued dental destruction, and it appears to be on the increase. Therefore, it becomes more strongly our professional duty to improve artificial cleanse-massage –and more difficult, to promulgate it for use among the laity, for it is an operation of the layman.

One means of promulgation is direct contact of the dentist or his assistant with the patient. Another one is the agencies of health and school organizations. Much has been done through all these means. But these media are far from being exhausted. And, they are not sufficient in themselves. There are many people who are not reached through these contacts.

The proof of it is this. If you make it a point to notice dental knowledge in a cross-section of the laity, you will observe they have, on the whole, a miserable conception and many archaic obsessions of dentistry. This is so despite the recent improvement of public dental knowledge over total ignorance of the laity in the past. We must realize that extensive education of dental matters has been mainly confined to dental circles.

Dental Education Needed

What is required is a better contact with the public to disseminate dental knowledge they need. To return to our main subject, at least they should be well trained in the important preventive operation we must entrust to them –an advanced technique in using the toothbrush.

We have no better means than the daily newspaper, the periodicals, the cinema, and the radio. These formidable agencies have a public prestige that is psychologically effective. If these means can be used so efficaciously for commercial enterprises, many of which are erroneous, if not misleading, why can not the media be effective ethically for something rational and sincere, striving to benefit the public weal?

It is true some of these agencies are used today to teach oral hygiene but in a minor way. They are not receiving equal opportunity of effective presentation. It is only by widespread and noticeable education that the needed results are obtainable. The profession is in a position to design and to possess scientific technical knowledge of dental care and prevention. The public needs it. We must enlist the proper media to transmit the knowledge.

We must also be aware that our students, laymen, have many other occupations, cares and needs; and that dentistry is not their main interest as it is ours. Neither will they interpret the instructions of using the toothbrush uniformly. We must expect different degrees of success. But some accomplishments to aid in prevention and defense against the onslaught of dental diseases is warmly welcome.

To succeed in teaching a technique and attracting permanent adherents to it, the method must be as simple as possible and orderly, yet embody all technical advantages. All the technical features may seem to complicate a good procedure with the toothbrush and make it appear a multitude of details must be kept in mind during each operation. But the only things necessary to follow are the few general rules of procedure described earlier in the article. The advantageous details within them will be automatically achieved without any special attention. Assiduous attention, however, to every rule is required for advantages of something that is scientific. Any abbreviations or aberrations, any carelessness or neglect, detract, and sometimes wholly, to defeat the purpose.

Here, then, is an instrument –the toothbrush, reaching the operation, used by multitudes of laymen everyday. Unfortunately most people are brushing their teeth without cleaning them, massaging their gums without impunity. Yet they are doing so with the false assumption they are deriving benefits. Little has their attention been called to good techniques. The basis of instruction has been meager. Why then, should we not endeavor to continue perfecting a rational technique for its use and then convey the knowledge effectively to the great number of people? It is a remarkable opportunity to assist in preventing disease, and retaining dental health.

2265 Davidson Avenue, New York, N.Y.








Irradiation of Foods

            Perhaps the most valuable contribution to the science of dietetics has been the discovery that it is possible to enrich the vitamin content of certain foods by exposing them to ultra-violet rays artificially produced. The pioneer of this investigation was Professor Steenbock, of the University of Wisconsin, who found that certain oils if suitably exposed to the vital rays could be endowed with a potent and constant amount of Vitamin D.

The creation of this Vitamin appears to depend upon the existence of a chemical compound known as ergosterol. This pro-vitamin, as it is called, is found widely in nature in small quantities. In actual practice, ergosterol is obtained commercially from yeast, and it can be “irradiated” to contain a standard amount of Vitamin D.

Now, cod-liver is the richest natural source of this vitamin, and as is well known, it has a well-merited reputation in the treatment of rickets, malnutrition in infancy and tuberculosis. For obvious reasons cod-liver oil is not convenient for addition to other foodstuffs, and hence the great value of irradiated ergosterol, which can be used to enhance the vitamin content of margarine, malt, dried milk and other foods.

Sun Lamp Treatment

            Modern appliances for artificial sun treatment have progressed considerably form Finsen’s carbon and lenses, and the mercury arc lamps of 1936, now most generally adopted for irradiation, show great improvements in economy, convenience, and efficiency on those of ten years ago. It is now possible to measure accurately the amount of energy given to the individual receiving sun treatment, and also the way in which each individual reacts to this amount.

Instead of exposing any weakly individual hap hazard to any source of light for any length of time, the exposure is carefully regulated according to the type of lamp and the reaction of the patient. For measuring the latter, Sir Leonard Hill and  Eil have introduced a method of estimating the exact dose required, using an instrument called a “sitometer.” This consists of a round aluminum plate to which is attached a clockwork mechanism which gradually moves a small screen covering a hole in the plate.

The apparatus is placed over the skin and the area exposed for different periods to the rays the lamp; the erythema, or redness of the skin produced is used to determine the exact amount which will be the most beneficial.

This exactitude, which was unknown to the pioneers in this branch of scientific treatment, is of great value in obtaining the best results from pressure to artificial sunlight without discomfort of the injury to the patient.



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