The effects of an ultrasonic toothbrush on plaque accumulation and gingival inflammation

A randomized, 3-month, parallel-group clinical trial to compare the efficacy of electric 3-dimensional toothbrushes vs manual toothbrushes in maintaining oral health in patients with fixed orthodontic appliances

INTRODUCTION

The aim of this single-blinded, parallel-group, randomized clinical trial was to compare the efficacy of electric 3-dimensional (3D) toothbrushes and manual toothbrushes in removing plaque and reducing gingival inflammation in orthodontic patients.

METHODS

Eighty adolescents with fixed orthodontic appliances in both arches were randomized at a 1:1 ratio, with an equal number of both sexes, in this examiner blinded, parallel clinical trial. Eligibility criteria included subjects aged between 12 and 16 years, good general health, nonextraction orthodontic treatment, and plaque-induced gingivitis, excluding patients with active caries or periodontitis, tooth agenesis, syndromes, disabilities, and craniofacial deformities, ≥2 cervical and/or proximal fillings, dental prostheses or dental implants, and subjects smoking or using antibiotics or medication predisposing to gingival enlargement. Patients were assigned to use either an electric 3D orthodontic toothbrush (Oral-B Pro-1000 with Oral-B Ortho head; Procter & Gamble, Cincinnati, Ohio) or a manual toothbrush (Oral-B Orthodontic brush; Procter & Gamble) and instructed to brush twice daily for 2 minutes. The main outcomes were: (1) plaque removal, assessed with the Modified Silness and Löe plaque index and the Modified Full Mouth Plaque Score, and (2) gingival inflammation reduction, assessed with the Modified Silness and Löe Gingival Index and the Modified Simplified Gingival Index. Measurements were taken at baseline, 1, 2, and 3 months. Randomization was achieved with 2 random sequences, one for each brush, written and sealed in opaque numbered envelopes. Blinding was possible for outcome assessment only.

RESULTS

Considerable variability was observed among patients in the values of all dependent variables. There was no difference between interventions over time for any of the outcomes, and the main effects for treatment and time were also not statistically significant. For Modified Silness and Löe plaque index, the interaction was 0.001 (95% confidence interval, -0.011 to 0.013; P = 0.89).

CONCLUSIONS

No difference in plaque removal efficacy and gingival inflammation reduction was found between the electric 3D and manual toothbrushes in adolescents with fixed orthodontic appliances. Therefore, orthodontists should focus on enhancing their patients' dental awareness and oral hygiene, along with professional prophylaxis and other oral hygiene aids, independently of the brush used.

REGISTRATION

This trial was registered at ClinicalTrials.gov (Identifier: NCT02699931).

PROTOCOL

The protocol was not published before trial commencement.

FUNDING

Electric and manual toothbrushes and toothpastes for all participants were provided by Procter & Gamble (Oral-B). Miscellaneous costs were covered by the participating departments.

Powered toothbrushes for plaque control in fixed orthodontic patients: a network meta-analysis

BACKGROUND

Orthodontic patients are at greater risk due to the inability to clean around the components directly bonded to teeth. Hence, the aim of the present network meta-analysis is to compare the utility of powered toothbrushes in plaque control in patients with orthodontic brackets compared with manual tooth brushing.

METHODOLOGY

Necessary data were extracted and analysed for Risk of Bias. Heterogeneity was assessed using Chi-square and I² tests. Random effects model was used for both direct and mixed treatment comparisons. Standardized mean difference with 95% confidence interval was the effect estimate for plaque and bleeding scores and mean difference for pocket depth. Inconsistencies between the direct and indirect estimates were evaluated by H-statistics. GRADE approach was used to assess the quality of evidence.

RESULTS

Pooled results from 14 studies showed significantly higher plaque scores in patients using manual toothbrushes. Pooled results from 13 studies showed significant higher bleeding scores as well with manual brushes. There was a significant reduction in pocket depth with electric toothbrushes.

CONCLUSION

Powered toothbrushes are a promising alternative for plaque control in patients with fixed orthodontic brackets. Stronger evidence can be established with addition of long-term clinical trials based on the recommendations.

Plaque Removal Efficacy of Different Toothbrushes: A Comparative Study

Aim and objective

This study aimed to compare the plaque removal efficacy of different toothbrushes and to ascertain the most efficient mechanical mean for daily plaque removal so as to maintain oral health in a preeminent way.

Study design

It was a randomized controlled clinical trial consisting of 60 subjects divided into three groups (group I ultrasonic and sonic toothbrush, group II multidirectional toothbrush, and group III manual toothbrush) with 20 in each group. Prebrushing and postbrushing plaque scores were recorded at weekly intervals for four weeks using Turesky modification of Quigley and Hein plaque index.

Results

Statistically significant differences (p < 0.001) existed in mean percent reduction of pre-day 1 to pre-day 28 mean percent reduction in plaque values of the ultrasonic toothbrush group (111.92 ± 25.20), the multidirectional toothbrush group (189.06 ± 52.70), and the manual toothbrush group (42.34 ± 14.77). Similar results were found in post-day 1 to post-day 28 mean percent reduction in plaque values.

Conclusion

Group II (i.e., multidirectional toothbrush) showed maximum mean percent reduction in prebrushing and postbrushing plaque scores at the end of four weeks when compared with the baseline values followed by ultrasonic toothbrush and manual toothbrush.

How to cite this article

Aggarwal N, Gupta S, Grover R, et al. Plaque Removal Efficacy of Different Toothbrushes: A Comparative Study. Int J Clin Pediatr Dent 2019;12(5):385-390.

Comparison of the effectiveness between power toothbrushes and manual toothbrushes for oral health: a systematic review and meta-analysis

Objective: Power toothbrushes is considered an effective tool for maintaining oral health; however, its efficacy as compared to manual toothbrushes is still not completely clarified. This article aims to evaluate the efficacy of power toothbrushes compared with the manual toothbrushes in terms of plaque, gingivitis and bleeding reduction.Methods: An electronic search was performed on PUBMED, Web of Science, Wiley and Research Gate. Studies comparing the effectiveness of plaque, gingivitis and bleeding reduction between power and manual toothbrushes were included. Results and effect sizes analysis are presented as standard mean difference (SMD), and subgroup analysis stratified by mode of action of the power toothbrush was performed. Study quality and risk of bias were assessed using the Cochrane assessment tool.Results: A total of 21 randomized clinical studies were included. Power toothbrushes were significantly more effective in reducing plaque index (26 trials: SMD = 0.86, 95% CI: 0.58 to 1.14, I² = 91.5%, p < .0001), gingival index (14 trials: SMD = 0.47, 95% CI: 0.12 to 0.82, I² = 88.7%, p < .0001), and bleeding index (11 trials: SMD = 0.92, 95% CI: 0.43 to 1.40, I² = 91.8%, p < .0001) compared with the manual toothbrushes, except that there was no significant differences between the oscillating-rotating toothbrushes and manual toothbrushes regarding gingivitis reduction (7 trials: SMD = 0.07, 95% CI: -0.20 to 0.33, I² = 57.2%, p = .03).Conclusions: Power toothbrushes is more effective in reducing dental plaque, gingivitis and bleeding compared with the manual toothbrush.

Dental Plaque Removal by Ultrasonic Toothbrushes

With the variety of toothbrushes on the market, the question arises, which toothbrush is best suited to maintain oral health? This thematic review focuses first on plaque formation mechanisms and then on the plaque removal effectiveness of ultrasonic toothbrushes and their potential in preventing oral diseases like periodontitis, gingivitis, and caries. We overviewed the physical effects that occurred during brushing and tried to address the question of whether ultrasonic toothbrushes effectively reduced the microbial burden by increasing the hydrodynamic forces. The results of published studies show that electric toothbrushes, which combine ultrasonic and sonic (or acoustic and mechanic) actions, may have the most promising effect on good oral health. Existing ultrasonic/sonic toothbrush models do not significantly differ regarding the removal of dental biofilm and the reduction of gingival inflammation compared with other electrically powered toothbrushes, whereas the manual toothbrushes show a lower effectiveness.

Safety and Design Aspects of Powered Toothbrush-A Narrative Review

The powered toothbrush has become a modern dental tool that is available in the supermarket. Indeed, the design of the powered toothbrush, e.g., mechanical and electrical, would affect not only the efficacy but also the safety of the products. This narrative review attempted to view the powered toothbrush from design, safety, and application points with respect to tufts, filaments, handles, mechanics, motions, and materials interactions from various available sources. Different brands and models of powered toothbrushes have their own designs that might affect the clinical outcome. The rotational design was advocated to be clinically more effective than the manual one, some modern models might be designed with vibrational or oscillation (or mixed) tufts head that might be useful in patients with specific needs, such as having xerostomia or for the elderly. To conclude, tuft retention design is important in the powered toothbrush as it contributes significantly to safety as the fallen off tufts, filaments and metal parts might cause injury. Tests revealing the retention force of brush head plates and brush head bristles will be significant references for consumers to determine which design of powered toothbrushes is relatively safer.

Effectiveness of a motionless ultrasonic toothbrush in reducing plaque and gingival inflammation in patients with fixed orthodontic appliances

OBJECTIVE

To compare the effectiveness of a motionless ultrasonic toothbrush to a manual toothbrush in reducing dental plaque, gingival inflammation, and mutans streptococci in patients with fixed orthodontic appliances.

MATERIALS AND METHODS

Twenty-five orthodontic patients were recruited to this crossover study. The patients were randomized into two groups starting with manual or motionless ultrasonic toothbrushes for 30 days. After a 30-day washout period, the patients switched to the other toothbrush type for 30 days. Plaque and gingival indices were evaluated by two calibrated-blinded examiners before and after each 30-day period of brushing. Salivary samples were also collected for quantification of mutans streptococci.

RESULTS

On the bracket side, the motionless ultrasonic toothbrush showed a significantly higher mean plaque index bracket score after 30-day usage than baseline (P = .049), while the manual toothbrush group showed no difference between the before and after brushing periods (P = .10). The changes in plaque index bracket score were significantly more favorable in the manual toothbrush group than in the ultrasonic toothbrush group (P = .04). In contrast, no difference was observed on the nonbracket side. There was no significant difference in the changes of gingival index or the numbers of mutans streptococci between the two groups.

CONCLUSION

Manual toothbrushing performed better than brushing with the motionless ultrasonic toothbrush in plaque removal on the bracket side in orthodontic patients. However, no difference was observed in terms of gingival status and the numbers of mutans streptococci.

A clinicomicrobiological study to evaluate the efficacy of manual and powered toothbrushes among autistic patients

AIM

To compare the efficacy of powered toothbrushes in improving gingival health and reducing salivary red complex counts as compared to manual toothbrushes, among autistic individuals.

MATERIALS AND METHODS

Forty autistics was selected. Test group received powered toothbrushes, and control group received manual toothbrushes. Plaque index and gingival index were recorded. Unstimulated saliva was collected for analysis of red complex organisms using polymerase chain reaction.

RESULTS

A statistically significant reduction in the plaque scores was seen over a period of 12 weeks in both the groups (P < 0.001 for tests and P = 0.002 for controls). This reduction was statistically more significant in the test group (P = 0.024). A statistically significant reduction in the gingival scores was seen over a period of 12 weeks in both the groups (P < 0.001 for tests and P = 0.001 for controls). This reduction was statistically more significant in the test group (P = 0.042). No statistically significant reduction in the detection rate of red complex organisms were seen at 4 weeks in both the groups.

CONCLUSION

Powered toothbrushes result in a significant overall improvement in gingival health when constant reinforcement of oral hygiene instructions is given.

Powered versus manual toothbrushing for oral health

BACKGROUND

Removing dental plaque may play a key role maintaining oral health. There is conflicting evidence for the relative merits of manual and powered toothbrushing in achieving this. This is an update of a Cochrane review first published in 2003, and previously updated in 2005.

OBJECTIVES

To compare manual and powered toothbrushes in everyday use, by people of any age, in relation to the removal of plaque, the health of the gingivae, staining and calculus, dependability, adverse effects and cost.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 23 January 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1), MEDLINE via OVID (1946 to 23 January 2014), EMBASE via OVID (1980 to 23 January 2014) and CINAHL via EBSCO (1980 to 23 January 2014). We searched the US National Institutes of Health Trials Register and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials of at least four weeks of unsupervised powered toothbrushing versus manual toothbrushing for oral health in children and adults.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. Random-effects models were used provided there were four or more studies included in the meta-analysis, otherwise fixed-effect models were used. Data were classed as short term (one to three months) and long term (greater than three months).

MAIN RESULTS

Fifty-six trials met the inclusion criteria; 51 trials involving 4624 participants provided data for meta-analysis. Five trials were at low risk of bias, five at high and 46 at unclear risk of bias.There is moderate quality evidence that powered toothbrushes provide a statistically significant benefit compared with manual toothbrushes with regard to the reduction of plaque in both the short term (standardised mean difference (SMD) -0.50 (95% confidence interval (CI) -0.70 to -0.31); 40 trials, n = 2871) and long term (SMD -0.47 (95% CI -0.82 to -0.11; 14 trials, n = 978). These results correspond to an 11% reduction in plaque for the Quigley Hein index (Turesky) in the short term and 21% reduction long term. Both meta-analyses showed high levels of heterogeneity (I(2) = 83% and 86% respectively) that was not explained by the different powered toothbrush type subgroups.With regard to gingivitis, there is moderate quality evidence that powered toothbrushes again provide a statistically significant benefit when compared with manual toothbrushes both in the short term (SMD -0.43 (95% CI -0.60 to -0.25); 44 trials, n = 3345) and long term (SMD -0.21 (95% CI -0.31 to -0.12); 16 trials, n = 1645). This corresponds to a 6% and 11% reduction in gingivitis for the Löe and Silness index respectively. Both meta-analyses showed high levels of heterogeneity (I(2) = 82% and 51% respectively) that was not explained by the different powered toothbrush type subgroups.The number of trials for each type of powered toothbrush varied: side to side (10 trials), counter oscillation (five trials), rotation oscillation (27 trials), circular (two trials), ultrasonic (seven trials), ionic (four trials) and unknown (five trials). The greatest body of evidence was for rotation oscillation brushes which demonstrated a statistically significant reduction in plaque and gingivitis at both time points.

AUTHORS' CONCLUSIONS

Powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term. The clinical importance of these findings remains unclear. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses.Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and only temporary.

A comparison of the efficacy of powered and manual toothbrushes in controlling plaque and gingivitis: a clinical study

BACKGROUND

Plaque is intimately related to the production and progress of dental caries and inflammatory gingival and periodontal diseases. Good plaque control facilitates the return to health for patients with gingival and periodontal diseases. Daily use of a toothbrush and other oral hygiene aids is the most dependable way to achieve oral health benefits for all patients.

METHODS

A randomized clinical trial was conducted to compare the efficacy of a powered toothbrush with a manual toothbrush in controlling plaque and gingivitis over a 6-week period. The sample consisted of 60 dental students of both sexes, with ages ranging from 18 to 28 years. The samples were stratified and randomly divided into two groups of 30 by a second examiner using the coin toss method; one group used a manual toothbrush and the other group used a powered toothbrush. Each participant's gingival index, plaque index and oral hygiene index were assessed on the seventh, 14th, and 45th days on the basis of the assigned toothbrush. Collected data were analyzed and different subgroups were compared using Student's t-test.

RESULTS

A paired t-test revealed a highly significant reduction in the gingival, plaque, and oral hygiene index scores of the manual and powered groups at the first, second, and sixth weeks (P-value < 0.0001). An unpaired t-test revealed a significant reduction between the plaque index scores of the manual and powered groups at the second week (P-value < 0.05). Another unpaired t-test revealed a highly significant reduction between the plaque index scores of the manual and powered groups at the sixth week (P-value < 0.0001).

CONCLUSION

The subject group using the powered toothbrush demonstrated clinical and statistical improvement in overall plaque scores. Powered toothbrushes offer an individual the ability to brush the teeth in a way that is optimal in terms of removing plaque and improving gingival health, conferring good brushing technique on all who use them, irrespective of manual dexterity or training.

The effectiveness of manual versus powered toothbrushes for plaque removal and gingival health: A meta-analysis

BACKGROUND

The aim of this systematic review and associated meta-analysis was to compare manual and powered brushes in relation to the removal of plaque and gingival health. Stain removal, adverse effects and microbiological evaluation cost were also considered.

MATERIALS AND METHODS

To be included in the review, a trial had to be a randomized-controlled trial (RCT) comparing manual and powered brushes. Trials confined to comparing different types of powered or different types of manual brushes were excluded. Split mouth designs were eligible. Trials with subjects of specific age group (18-25 years) were included. The primary outcomes were plaque and gingival health with data defined as short-term (0-28 days) duration were analyzed. Powered brushes were categorized into three groups depending on mode of action. Numerical data extracted were checked by a fourth reviewer for accuracy.

RESULTS

Three trials with full articles were identified. These include trials published between 2002 and 2005. The trials involved 56 subjects at baseline, without loss of subject for follow up. Powered brushes reduced plaque and gingivitis at least as effectively as manual brushing. Ionic brushes statistically significantly reduced plaque and gingivitis.

CONCLUSION

In general there was no evidence of a statistically significant difference between powered and manual brushes. However, ionic brushes significantly reduce plaque and gingivitis in both the short-term evaluations. The clinical significance of this reduction is not known. Observation of methodological guidelines and greater standardization of design would benefit both future trials and meta-analyses.

A study of the efficacy of ultrasonic waves in removing biofilms

OBJECTIVE

The removal of adherent biofilms was assessed using ultrasonic waves in a non-contact mode.

MATERIALS AND METHODS

In in vitro experiments, Streptococcus mutans (S. mutans) biofilms were exposed to ultrasonic waves at various frequencies (280 kHz, 1 MHz, or 2 MHz), duty ratios (0-90%), and exposure times (1-3 minutes), and the optimal conditions for biofilm removal were identified. Furthermore, the effect of adding a contrast medium, such as micro bubbles (Sonazoid), was examined. The spatial distribution and architecture of S. mutans biofilms before and after ultrasonic wave exposure were examined via scanning electron microscopy. The biofilm removal effect was also examined in in vivo experiments, using a custom-made oral cleaning device.

RESULTS

When a 280 kHz probe was used, the biofilm-removing effect increased significantly compared to 1 and 2 MHz probes; more than 80% of the adherent biofilm was removed with a duty cycle of 50-90% and a 3 minutes exposure time. The maximum biofilm-removing effect was observed with a duty cycle of 80%. Furthermore, the addition of micro bubbles enhanced this biofilm-removing effect. In in vivo experiments, moderate biofilm removal was observed when a 280 kHz probe was used for 5 minutes.

CONCLUSIONS

This study demonstrated that ultrasonic wave exposure in a non-contact mode effectively removed adherent biofilms composed of S. mutans in vitro.

Comparison of manual versus sonic and ultrasonic toothbrushes: a review

PURPOSE

This review of the literature intends to evaluate the effect of brushes with high frequency motion when compared with manual toothbrushes regarding the indices of plaque and gingival bleeding.

METHODS

Patients presenting gingivitis and/or chronic periodontitis were evaluated in addition to patients having osseointegrated implants and fixed orthodontic appliances. Pertinent literature was reviewed to select articles according to previously defined inclusion criteria.

RESULTS

In the assessed studies results showed significant decreases in plaque and gingival indices by utilization of both types of brushes. However, in the selected studies where sonic brushes were tested in orthodontic and dental implant patients there was a more significant decrease in the indices. Furthermore, there was no indication of gingival recession attributed to product use.

CONCLUSION

Future studies with a more homogeneous methodology and better experiment designs will be needed.

Quality of trials in a systematic review of powered toothbrushes: suggestions for future clinical trials

BACKGROUND

This study aimed to assess the quality of reports of randomized controlled trials (RCTs) comparing manual and powered toothbrushes and provide advice on how future trials might be improved.

METHODS

Studies were identified in the Cochrane systematic review of RCTs comparing powered versus manual toothbrushes. Reports were assessed against predefined criteria on the design of the studies to determine the effectiveness of the brushes in everyday home use and on their methodological quality.

RESULTS

Only 42 of 297 identified studies satisfied the inclusion criteria and were eligible for inclusion in the review. Many studies were excluded for more than one reason. Fifteen studies employed split-mouth designs that may have changed toothbrushing behavior. Of 42 included RCTs, the generation of randomization sequence was adequate in 15 trials and concealment of allocation was adequate in 16 trials. Intention-to-treat analysis was reported in only five studies. Plaque data were reported using 10 different indices and gingivitis with nine indices. Only 12 trials lasted 3 months or longer, and there were no data on the benefits of powered toothbrushes for periodontal attachment.

CONCLUSIONS

Some designs created an artificial research environment that may have undermined the findings. Authors of toothbrush trials should consider the Consolidated Standards of Reporting Trials statement. Greater standardization of the indices used is required. Trials of longer duration would enhance the evaluation of powered toothbrushes. Data on thresholds for clinically significant differences in plaque and gingivitis levels would help to determine whether oral hygiene aids provide important health benefits.

Efficacy of Ultrasonic, Electric and Manual Toothbrushes in Patients with Fixed Orthodontic Appliances

OBJECTIVE

This crossover study compared the efficacy of an ultrasonic toothbrush for the reduction of plaque, gingival inflammation, and levels of Streptococcus mutans, in relation to an electric and a manual toothbrush.

MATERIALS AND METHODS

Twenty-one patients with orthodontic appliances were divided into three groups. All patients were evaluated by a periodontist and samples of saliva were collected for quantification of S mutans. The patients received their first brushes with appropriate instructions. For each crossover leg, patients used each toothbrush for a period of 30 days. At the end of each washout period, participants received a periodontal evaluation and new samples of saliva were collected. After 15 days of using their own toothbrushes, patients received the next toothbrushes in the experimental sequence.

RESULTS

The ultrasonic brush group presented significant improvement in the reduction of visible plaque on the buccal surfaces (-6.36%, P = .007). The counts of S mutans decreased in the electric (2.04 x 10(5) to 1.36 x 10(5) colony-forming units [CFU]/mL) and ultrasonic (2.98 x 10(5) to 1.84 x 10(5) CFU/mL) groups. There were no statistical differences among the three brushes for the clinical and microbiological parameters evaluated.

CONCLUSIONS

This study did not demonstrate that the ultrasonic toothbrush was better in reducing gingival inflammation in adolescent orthodontic patients, but plaque scores were lowered on buccal surfaces of teeth with orthodontic brackets. In addition, S mutans counts were markedly decreased in the electric and ultrasonic groups, which should be related to a reduced risk of oral disease.

Manual versus powered toothbrushing for oral health

BACKGROUND

Removing dental plaque may play a key role maintaining oral health. There is conflicting evidence for the relative merits of manual and powered toothbrushing in achieving this.

OBJECTIVES

To compare manual and powered toothbrushes in relation to the removal of plaque, the health of the gingivae, staining and calculus, dependability, adverse effects and cost.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register (to 17/06/2004) and Central Register of Controlled Trials (The Cochrane Library Issue 2, 2004); MEDLINE (January 1966 to week 2 June 2004); EMBASE (January 1980 to week 2 2004) and CINAHL (January 1982 to week 2 June 2004). Manufacturers were contacted for additional data.

SELECTION CRITERIA

Trials were selected for the following criteria: design-random allocation of participants; participants - general public with uncompromised manual dexterity; intervention - unsupervised manual and powered toothbrushing for at least 4 weeks. Primary outcomes were the change in plaque and gingivitis over that period.

DATA COLLECTION AND ANALYSIS

Six authors independently extracted information. The effect measure for each meta-analysis was the standardised mean difference (SMD) with 95% confidence intervals (CI) using random-effects models. Potential sources of heterogeneity were examined, along with sensitivity analyses for quality and publication bias. For discussion purposes SMD was translated into percentage change.

MAIN RESULTS

Forty-two trials, involving 3855 participants, provided data. Brushes with a rotation oscillation action removed plaque and reduced gingivitis more effectively than manual brushes in the short term and reduced gingivitis scores in studies over 3 months. For plaque at 1 to 3 months the SMD was -0.43 (95% CI: -0.72 to -0.14), for gingivitis SMD -0.62 (95% CI: -0.90 to -0.34) representing an 11% difference on the Quigley Hein plaque index and a 6% reduction on the Loe and Silness gingival index. At over 3 months the SMD for plaque was -1.29 (95% CI: -2.67 to 0.08) and for gingivitis was -0.51 (-0.76 to -0.25) representing a 17% reduction on the Ainamo Bay bleeding on probing index. There was heterogeneity between the trials for the short-term follow up. Sensitivity analyses revealed the results to be robust when selecting trials of high quality. There was no evidence of any publication bias. No other powered designs were as consistently superior to manual toothbrushes.Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and temporary.

AUTHORS' CONCLUSIONS

Powered toothbrushes with a rotation oscillation action reduce plaque and gingivitis more than manual toothbrushing. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses.

Assessing adherence with toothbrushing instructions using a data logger toothbrush

OBJECTIVES

To evaluate patient compliance with toothbrushing instructions using a data logger and a brushing diary.

METHODS

Dental patients were provided with powered toothbrushes modified to carry electronic data loggers. Demonstration of the most effective way to use the toothbrush was provided with instructions to brush for 2 minutes morning and evening. Data logger brushes were supplied for two episodes of 8 weeks. Brushing time was also recorded in a diary during episode 1.

RESULTS

Data from 14 brushes (2,287 recordings) were used to evaluate compliance in episode 1 Nine brushes (1,526 recordings) were used in episode 2 A total of 2,333 brushing events were reported manually in the diaries. Data logger records during episode 1 showed that only 34% of events were compliant with the instruction of a 2 minute brushing time, 20% were partially compliant (within +/-30s of 2 minutes), and 46% of events were non-compliant (>30s from 2 minutes). The respective proportions for episode 2 were 24%, 24% and 52%. Diary data reported 58% of events as compliant with 42% non-compliant.

CONCLUSIONS

Manually completed brushing diaries do not provide an accurate reflection of subjects' compliance with toothbrushing instructions.

The effectiveness of manual versus powered toothbrushes for dental health: a systematic review

OBJECTIVES

To compare manual and powered toothbrushes in everyday use, principally in relation to plaque removal and gingival health. Stain, calculus removal, dependability, adverse effects and cost were also considered.

METHOD

A systematic review was undertaken in collaboration with the Cochrane Oral Health Group. Five electronic databases were searched to identify randomised controlled trials comparing powered and manual toothbrushes. Trials of less than 28 days duration, or where toothbrushing was supervised, were excluded. Assessment of relevance, data extraction and validity assessment were all undertaken independently and in duplicate by two reviewers. Included studies were grouped according to the mode of action of the powered toothbrush. The primary outcomes were plaque and gingival health with data defined as either short-term (1-3 months) or long-term (greater than 3 months) duration were analysed. Powered brushes were categorised into six groups depending on mode of action. Numerical data extracted were checked by a third reviewer for accuracy and entered into RevMan (version 4.1).

RESULTS

The initial search identified 354 studies. Two hundred and fifteen full articles were obtained of which 29 trials fulfilled the inclusion criteria with results, which could be entered in the meta-analysis. Twenty-six trials (1786 participants) reported short-term and 10 trials (798 participants) long-term plaque scores. Twenty-nine trials (2236 participants) reported short-term and 10 trials (798 participants) long-term gingivitis scores. Powered brushes reduced plaque and gingivitis at least as effectively as manual brushing. Rotation oscillation powered brushes statistically significantly reduced plaque and gingivitis in both the short and long-term. For plaque at one to 3 months the standardised mean difference was -0.44 (95% CI: -0.66 to -0.21), for gingivitis SMD -0.45 (95% CI: -0.76, -0.15). These represented an 11% reduction on the Quigley Hein Plaque index and a 6% reduction on the Löe and Silness gingival index. At over 3 months the effects were SMD for plaque -1.15 (95% CI: -2.02, -0.29) and SMD for gingivitis -0.51 (95% CI: -0.76, -0.25). These represented a 7% reduction on the Quigley Hein Plaque Index and a 17% reduction on the Ainamo Bay Bleeding on Probing Gingival Index. Sensitivity analyses revealed the results to be robust when selecting trials of high quality. There was no evidence of any publication bias. No other powered brush designs were consistently superior to manual toothbrushes. In these trials, data on cost, reliability and side effects were inconsistently reported.

CONCLUSION

In general there was no evidence of a statistically significant difference between powered and manual brushes. However, rotation oscillation powered brushes significantly reduce plaque and gingivitis in both the short and long-term. The clinical significance of this reduction is not known. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses.

A systematic review of powered vs manual toothbrushes in periodontal cause-related therapy

BACKGROUND

Power-driven toothbrushes (PDT) have been designed to improve the efficacy of oral hygiene. It is not clear how they compare in efficacy with manual toothbrushes in cause-related periodontal therapy.

OBJECTIVES

To evaluate the effectiveness of the use of a PDT as compared with a manual toothbrush (MT), in terms of gingival bleeding or inflammation resolution, in cause-related periodontal therapy.

MATERIAL AND METHODS

An electronic (MEDLINE and Cochrane Oral Health Group Specialised Trials Register) and a manual search were made to detect studies which permitted the evaluation of the efficacy of PDT in the reduction of gingival bleeding or inflammation, and their effect on other secondary variables. Only randomized studies in adults, published in English up to June 2001, which compared a PDT with an MT, and evaluated the evolution of gingival bleeding or inflammation were included. The selection of articles, extraction of data and assessment of validity were made independently by several reviewers.

RESULTS

Twenty-one studies were finally selected. The heterogeneity of the data prevented a quantitative analysis. A higher efficacy in the reduction of gingival bleeding or inflammation in the PDT patients was detected in 10 studies. This effect appears to be related to the capacity to reduce plaque, and is more evident in counter-rotational and oscillating-rotating brushes. No solid evidence was found for a higher efficacy of sonic brushes. In short-term studies with prophylaxis after initial examination, independently of the type of PDT tested, no significant differences were found.

CONCLUSION

The use of PDT, especially counter-rotational and oscillating-rotating brushes, can be beneficial in reducing the levels of gingival bleeding or inflammation. There is a need for methodological homogeneity in future studies in this field to enable quantitative analysis of their results.

Manual versus powered toothbrushing for oral health

BACKGROUND

Specific oral bacteria, generically known as "dental plaque" are the primary cause of gingivitis (gum disease) and caries. The removal of dental plaque is thought to play a key role in the maintenance of oral health. There is conflicting evidence for the relative merits of manual and powered toothbrushing in achieving this.

OBJECTIVES

To compare manual and powered toothbrushes in relation to the removal of plaque, the health of the gingivae, staining and calculus, dependability, adverse effects and cost.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (to 22/8/02); Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2002); MEDLINE (January 1966 to week 5 2002); EMBASE (January 1980 to week 3 July 2002) and CINAHL (January 1982 to June 2002). Manufacturers of powered toothbrushes were contacted for additional published and unpublished trials.

SELECTION CRITERIA

Trials were selected if they met the following criteria: design-random allocation of participants; participants-general public with uncompromised manual dexterity; intervention- supervised manual and powered toothbrushing for at least four weeks; primary outcomes-the change in plaque and gingivitis over that period.

DATA COLLECTION AND ANALYSIS

Six reviewers independently extracted information in duplicate. Indices for plaque and gingivitis were expressed as standardised values for each study. The effect measure for each meta-analysis was the standardised mean difference (SMD) with the appropriate 95% confidence intervals (CI) using random effect models. Potential sources of heterogeneity were examined, along with sensitivity analyses for the items assessed for quality and publication bias.

MAIN RESULTS

Twenty-nine trials, involving 2,547 participants, provided data for the meta-analysis. Brushes that worked with a rotation oscillation action removed more plaque and reduced gingivitis more effectively than manual brushes in the short and long term. For plaque at one to three months the SMD was -0.44 (95% CI: -0.66 to -0.21), for gingivitis SMD -0.44 (95% CI: -0.72, -0.15). These represented an 11% reduction on the Quigley Hein plaque index and a 6% reduction on the Löe and Silness gingival index. At over three months the effects were SMD for plaque -1.15 (95% CI: -2.02,-0.29) and SMD for gingivitis -0.51 (95% CI: -0.76, -0.25). These represented a 7% reduction on the Quigley Hein Plaque Index and a 17% reduction on the Ainamo Bay Bleeding on Probing Gingival Index. The heterogeneity found in these meta-analyses for short term trials was caused by one trial that had exceptionally low standard deviations. Sensitivity analyses revealed the results to be robust when selecting trials of high quality. There was no evidence of any publication bias. No other powered brush designs were consistently superior to manual toothbrushes. In these trials, data on cost, reliability and side effects were inconsistently reported. Those side effects that were reported on in the trials were localised and temporary.

REVIEWER'S CONCLUSIONS

Powered toothbrushes with a rotation oscillation action achieve a modest reduction in plaque and gingivitis compared to manual toothbrushing. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses.

Clinical efficacy of a new sonic/ultrasonic toothbrush

OBJECTIVES

The purpose of this clinical study was to evaluate the efficacy of the Ultra Sonex Ultima(R) in comparison with a conventional manual toothbrush.

MATERIAL AND METHODS

In all, 64 healthy volunteers (32 females, 32 males) took part in the parallel-design treatment-blind study. After a screening examination and stratification by age, sex and papillary bleeding index (PBI), the participants were randomly assigned to two groups with 32 subjects each. Four weeks later, the Turesky modification of the Quigley-Hein plaque index (PI), the approximal plaque index (API), and the PBI were recorded at baseline. Four and 8 weeks after baseline, the indices were recorded again.

RESULTS

During the study period of 8 weeks, the API showed no difference between the manual and the electric toothbrush. For the median PI, a statistically significant difference (p < 0.001) was found after 4 (manual: 2.16 vs. electric: 1.34) and 8 weeks (1.96 vs. 0.92). After 4 weeks, the median PBI was 0.75 for the manual and 0.43 for the electric brush (p < 0.01). The values after 8 weeks were 0.63 (manual) and 0.29 (electric, p < 0.001).

CONCLUSION

The Ultra Sonex Ultima may be more efficacious than manual toothbrushes in removing plaque and preventing gingivitis in patients without severe periodontal disease.

A clinical evaluation of a novel data logger to determine compliance with the use of powered toothbrushes

OBJECTIVES

The primary objective of this study was to evaluate the viability of an electronic data logger to record the brushing episodes of patients receiving standardised oral hygiene instructions. The secondary objective was to estimate the compliance of a group of patients diagnosed with chronic periodontal disease with brushing time instructions for the daily use of a powered toothbrush over a 2-month period.

MATERIAL AND METHODS

17 modified Philips Jordan Sensiflex 2000 powered toothbrushes (PTBs) were provided to patients (32-67 years) attending for non-surgical management of chronic periodontal disease. The PTBs incorporated an electronic data logger which recorded, for each individual brushing event: the length of time the brush was used (identifying the brushing speed setting); the maximum, minimum and average current during operation; and the time spent charging in between two consecutive brushing events. The patients were given detailed instructions with the PTB and were told to use it for 2 min each morning and 2 min in the evening. The patients returned for non-surgical management over two visits prior to reinforcement of the oral hygiene instructions 1 month after PTB allocation. Subjects were asked to complete a simple brushing diary to record their use of the toothbrush on a daily basis. After 2 months of using the PTBs at home, the brushes and diaries were collected and the data downloaded from the data loggers.

RESULTS

Of the 17 data loggers allocated, two recorded no information and two subjects did not return for the follow-up appointments. The data from the remaining 13 data loggers were evaluated for level of compliance. An event of brushing between 120 and 130 s was considered to be compliant, one of between 90 and 120 or 130-150 s was partially compliant and brushing for < 90 s or > 150 s was recorded as non-compliant. Percentage compliance for all the events (2087 recordings) was 34%, partial- and non-compliance were calculated as: 18%; 48% of events, respectively.

CONCLUSION

This data logger has provided previously unrecorded data on the brushing times for a group of patients using a powered toothbrush at home during non-surgical management of chronic periodontal disease. The data suggested that almost half (48%) of the brushing events recorded by the data loggers were greater than 30 s above or below the instructed brushing time.

Clinical evidence for the efficacy and safety of powered toothbrushes

Powered toothbrushes are becoming increasingly popular among the general population, and there are many models on the market from which to choose. The design of these toothbrushes is changing constantly, as one would expect with a developing and expanding market, and from the dental professional's standpoint, it is difficult to evaluate products from the literature simply because the designs of clinical trials for powered toothbrushes are so varied. For example, the cohort recruited for testing the products is seldom the same from one study to the next. The aim of this paper is to provide a brief overview of the findings from some of the more contemporary trials of powered toothbrushes and to examine some of the factors that might have an effect on the observations and outcomes.

Preventive strategies and supportive treatment

There is a preponderance of evidence in the literature that periodontal and other oral diseases, such as caries, can be treated and controlled by thorough mechanical plaque removal by the patient, the use of antimicrobial agents and antibiotics when necessary, and participation with the therapist in a well monitored, long-range program of supportive periodontal therapy. Recent evidence suggests that the control and prevention of oral disease, especially periodontitis, is especially important for patients with various systemic conditions that can be impacted by oral infections. It is far better for patients and therapists to practice primary and even secondary prevention with effective plaque control and regular, consistent supportive periodontal therapy, than having to rely on tertiary prevention for disease that has progressed to a level that requires costly treatment, is time-consuming and carries a greater risk of morbidity.