Download Electric versus manual toothbrushes in the fixed orthodontic patient

Electric versus manual toothbrushes in the
fixed orthodontic patient: an evidence-based
review
COMMUNITY DENTISTRY
DEN207Y1
Kerry D’Costa
Ralph Dana
Gavin Ip
Eleanor Kong
Inna Vol
Course Director: Dr. Amir Azarpazhooh
Teaching Assistant: Dr. Ihab Suwwan
Submitted: April 5, 2011
UIVERSITY OF TOROTO
FACULTY OF DETISTRY
Electric versus manual toothbrushes in the fixed orthodontic patient
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ABSTRACT
Background: Plaque and debris that accumulate gingivally to orthodontic bands, brackets and archwires
are notoriously challenging to remove, leading to increased plaque levels and deteriorated gingival health.
In choosing a toothbrush, the fixed orthodontic patient may choose between various electric and manual
modalities. Objectives: To perform a review of the literature to determine the effectiveness of electric
toothbrushes compared to manual toothbrushes in patients with fixed orthodontics. Indicators used in
comparing the effectiveness of the intervention and control included one or several of the following:
plaque indices, gingival indices, bacterial indices, pocket depths, and bleeding indices. Search methods:
A search of the literature was conducted, primarily through computerized searches of PubMed based on
keywords and MeSH. Selection criteria/Data collection: 65 studies that met our PICOC criteria were
included. Of these, 18 articles remained after elimination at the title and abstract stages. These 18 articles
were reviewed and critically appraised. Strict inclusion and exclusion criteria were used to keep the report
systematic and relevant. Of these 18 articles, 8 were eliminated at the full copy stage, 2 failed to achieve
the required minimum 9/15 on our modified “Efficacy of Therapy” checklist, and finally 8 were included
as evidence in our review. The 8 articles were then evaluated using the Canadian Task Force
Recommendations. Results: Of the 8 studies reviewed, 4 concluded that electric toothbrushes offered
statistically significant benefits in at least one area, 3 concluded that there as no statistical difference
between brushes, and 1 concluded that manual toothbrushes were better at most outcomes assessed.
Electric toothbrushes performed at an equal level with manual toothbrushes with regard to plaque index
and gingival index. In 3 of 4 studies, powered brushes outperformed manual brushes in bleeding on
probing. Author’s conclusions: Electric toothbrushes perform at least equally as well as manual
toothbrushes in the orthodontic patient—and likely offer slight improvements with regard to plaque index
and bleeding on probing. It is unclear whether these improvements are clinically significant; accordingly,
it is uncertain whether the greater costs of powered toothbrushes are justified. A certain subset of fixed
orthodontic patients (i.e. impaired manual dexterity, recessed gums) may derive the greatest benefits from
powered toothbrushes.
MeSH keywords: Toothbrushing/instrumentation, orthodontics
Keywords: Orthodontics, braces, brackets, electric, oscillating, powered, toothbrush
Summary: Our goal was to determine whether manual or powered toothbrushes were more effective in
achieving good oral health in the orthodontic patient. After a thorough electronic search of the available
literature, we conclude that, although it is likely that powered toothbrushes provide some improvements
in oral health compared with manual toothbrushes, these improvements are not strong enough to justify
powered toothbrushes’ greater cost.
Electric versus manual toothbrushes in the fixed orthodontic patient
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BACKGROUD
It is well accepted within the dental profession that failure to remove plaque from all tooth surfaces
increases one’s risk of enamel decalcification, caries, and periodontal disease1; accordingly, regular and
effective oral hygiene is paramount in the prevention of oral disease2. Unfortunately, the majority of
patients do not take enough time to brush their teeth adequately2. The scenario evidently becomes even
worse when fixed orthodontic appliances are placed intraorally, with effective plaque removal being
obstructed to a discernible degree3.
Plaque and debris that accumulate gingivally to orthodontic wires are notoriously challenging to remove4
—orthodontic bands, brackets and archwires can obstruct toothbrush bristles and floss, leading to
increased plaque levels and subsequent decreases in gingival health5. The following pathological changes
generally occur in orthodontic patients some time after fixed orthodontic brackets are placed: gingival
inflammation and bleeding, gingival enlargement, and increased pocket depths5,6,7. Furthermore, there are
microbial changes in the subgingival periodontal flora associated with the placement orthodontic
brackets, namely decreases in gram positive cocci and increases in spirochetes, motile rods and other
gram negative organisms such as Actinobacillus, Bacteroides, and Prevotella5,6,8,9. In sum, the orthodontic
patient shows “detrimental changes in dental plaque pH, carbohydrate content, and the adherent microbial
flora”10.
These “detrimental changes”10 can be and often are a source of oral pathology unless the given patient
maintains adequate oral hygiene with daily toothbrushing and flossing. In considering the average
orthodontic patient, it is easy to envision that flossing often becomes more difficult and time demanding
when fixed orthodontic brackets are present, likely resulting in a less-than-daily usage pattern. As a result,
effective toothbrushing plays an even more critical role as a preventive measure in these patients5.
An array of toothbrushes—manual and electric—have been developed and marketed for use in
orthodontic and non-orthodontic patients. Robinson et al.’s article conveniently categorizes the array of
powered toothbrushes based on their mode of action: circular acting toothbrushes, counter-oscillation
acting toothbrushes, ionic toothbrushes, rotation-oscillation acting toothbrushes, side-to-side acting
toothbrushes, ultrasonic toothbrushes, and unknown action toothbrushes11. Additionally, there are various
orthodontic heads that have been developed for use with a variety of powered toothbrushes. We should
note that there are further options available for orthodontic patients. Besides the option to use
conventional manual toothbrushes, orthodontic patients may also choose from a selection of manual
toothbrushes that have been engineered specifically for use with fixed brackets. Most manual orthodontic
toothbrushes feature a V-shaped groove along the long axis of the toothbrush head4. In this configuration,
the shorter bristles in the V-shaped groove are progressively firmer and thus more effective in eliminating
debris from the midbracket region, while the longer bristles are more effective in eliminating debris from
the bracket-wing region4. The focus of our review is on the effectiveness of powered toothbrushes versus
manual toothbrushes in the fixed orthodontic patient. Accordingly, as will be discussed in more detail
later, we methodically searched for studies which compare and feature powered toothbrushes as an
intervention and manual toothbrushes as a control. Due to the scope of toothbrushes available, we felt that
it would be appropriate to consider nearly the whole range of toothbrushes available to the orthodontic
patient, though some distinctions will be made later.
Electric versus manual toothbrushes in the fixed orthodontic patient
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Individual studies comparing the effectiveness of electric toothbrushes with manual toothbrushes have
historically provided conflicting results1,2,4,11. With respect to non-orthodontic patients, Robinson’s
systematic review of the literature found that, among the various modes of action of electric toothbrushes,
only rotation oscillation action toothbrushes were better than manual toothbrushes at removing plaque and
reducing gum inflammation11. However, as Thienpont points out, a toothbrush that performs well in nonorthodontic patients may not necessarily work well in orthodontic patients2. The contrary is likely true as
well: a toothbrush that does not provide superior results in non-orthodontic patients may nevertheless
provide superior outcomes in an orthodontic patient. Accordingly, it is important to look at studies
specifically done on orthodontic patients in assessing whether powered toothbrushes may be of some
added benefit to this category of patient.
The reader may point out that there have been two relatively recent reviews that appraise the effectiveness
of powered toothbrushes for orthodontic patients—Costa et al’s 2007 review 12 and Kaklamanos and
Kalfas’ 2008 review13. Is there a need for another review in the year 2011? In our opinion, there is.
Firstly, new studies have been conducted since 2008. Furthermore, Costa et al’s review only accounts for
sonic and ultrasonic electric toothbrushes; as well, the review’s main focus is on non-orthodontic
patients12. Kaklamanos and Kalfas focus specifically on orthodontic patients and looks at all relevant
modes of action of powered toothbrushes; they conclude that there is “insufficient evidence to support the
comparative efficacy of powered toothbrushes in reducing gingivitis in patients undergoing fixed
orthodontic appliance therapy”13. Kaklamanos and Kalfas use very stringent criteria in selecting their
papers13, excluding various studies which we believe encompass findings that are relevant to the question
being posed. Furthermore, Kaklamanos and Kalfas only consider the effectiveness of powered
toothbrushes versus manual toothbrushes in reducing gingival inflammation in orthodontic patients13. We
felt that other relevant outcomes were equally important in investigating whether powered toothbrushes
could be of some added benefit to orthodontic patients.
OBJECTIVES
An evidence-based review of the literature was performed to evaluate the effectiveness of powered
toothbrushes compared to manual toothbrushes in patients with fixed orthodontics. Indicators used in
comparing the effectiveness of the intervention and control included one or several of the following:
plaque indices, gingival indices, bacterial indices, pocket depths, and bleeding indices. Patient preference,
if available, was also considered as an outcome of interest.
MATERIALS AD METHODS
Criteria for considering studies for this review
A systematic strategy was used to appraise the efficacy of powered toothbrushes in comparison to manual
toothbrushes in patients with fixed orthodontic appliances. Utilizing the systematic method, articles
suitable for this review were selected and critically evaluated.
Search methods for identification of studies
Electronic search
To search for articles relevant to the subject matter, the PubMed database was used. Two search strategies
approved by the librarian were utilized. The first search strategy consisted of a combination of the
Electric versus manual toothbrushes in the fixed orthodontic patient
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keywords (orthodontics OR braces OR brackets) AND (electric OR oscillating OR powered) AND
toothbrush. The second search strategy utilized the Mesh application, and was performed using the
keywords toothbrushing/instrumentation AND orthodontics. The search was limited to articles available
locally through the University of Toronto Library system and articles published in the English language.
Data collection and analysis
Selection of studies
The first PubMed search strategy yielded 14 results, and the second strategy yielded 61 results. 11 results
were duplicated between the two searches, thus the two PubMed search strategies in combination yielded
64 article results. One additional article was added from Google Scholar, for a total of 65 articles at the
preliminary stage. These articles were screened by the group and evaluated at the title stage. To select or
eliminate articles at the title stage, the initially established PICO guidelines were used (Table 1).
Table 1: Inclusion and Exclusion Criteria
Inclusion Criteria
Exclusion Criteria
Healthy individuals
Population
Males and females
Any age, any location
Wearing fixed orthodontic appliances on
maxilla and/or mandible
Oscillating toothbrush
Ionic toothbrush
Intervention
Rotating toothbrush
Manual toothbrush
Control
Plaque index
Outcome
Bacterial index
Gingival index
Bleeding on probing
Employing this PICO framework, relevant articles were selected at the title stage pending the agreement
of at least three out of the five group members. After the elimination at the title stage, 37 articles
remained. These remaining articles were then divided between the group members to be screened at the
abstract stage, such that each abstract is evaluated by at least two group members. At this stage, selection
criteria additional to those listed above were implemented:
Inclusion criteria:
- Articles reported primary research only
- Studies performed in-vivo only
- Articles published after 1990
- At least 4+ weeks of treatment with the brush of interest
- Manual toothbrush only used as control
Exclusion criteria:
- Reviews and commentaries were excluded
- Articles published prior to 1990
Electric versus manual toothbrushes in the fixed orthodontic patient
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Any intervention other than powered or manual toothbrush (such as flossing, mouthrinse, topical
fluoride)
Duration of intervention was shorter than 4 weeks
The decision to exclude articles published prior to 1990 was made based on the outdated versions of
powered toothbrushes used in these studies, which are no longer available on the market today. The
decision to exclude studies in which the duration of intervention was shorter than 4 weeks was based on
reviewing previous studies, which concluded that an observation period of minimum 4 weeks was
required to observe significant changes in plaque and bleeding index, as well as to eliminate results that
are based on chance occurrences2,14.
Following elimination at the abstract stage, 18 articles remained. These were then re-divided for
elimination at the full text stage, such that each article is read by at least two group members. Articles
were evaluated at the full text stage based on the same inclusion and exclusion criteria. Following
elimination at this stage, 12 articles were deemed suitable for the analysis.
Data extraction and report criteria
Each of the 12 remaining articles was scored according to the “Checklist to Assess Evidence of Efficacy
of Therapy or Prevention”15,16 (see Appendix A). A maximum score of 15 for each article could be
obtained on the checklist. A group decision was made to establish the cut-off score for inclusion at 9/15,
as this would indicate a study of sufficient quality to be included in the analysis. Out of the 12 remaining
articles, 4 did not meet the cut-off (see Appendix B), and therefore 8 studies remained for the final
analysis.
The remaining 8 articles were summarized into abstraction sheets. Abstraction sheets were created by at
least two group members for each article. The information from the abstraction sheets was then extracted
into an evidence table summarizing the 8 articles analysed in this study. The evidence table formed the
basis for drawing the conclusions of this review and contained the following information for each study:
author and date of publication, population of study, intervention, control used, outcomes and a critical
appraisal regarding the strengths/weaknesses of evidence. Finally, a classification of the study was made,
and the level of evidence was scored (I to III) based on the Canadian Task Force on Preventive Health
Care scoring system.
RESULTS
This review looks at a select number of studies that investigate whether electric toothbrushes are better
than manual toothbrushes in maintaining good oral hygiene for patients with fixed orthodontic braces. As
outlined in Appendix B, two separate search strategies were employed in selecting studies for this review.
Using the inclusion and exclusion criteria outlined in Table 1, our initial search results were narrowed
first at the Title Stage, second at the Abstract Stage, and third at the Full Copy Stage. The remaining
twelve studies, all randomized control trials, were further streamlined to eight studies based on an
“Efficacy of Therapy” checklist (see Appendix A) with a minimum score of 9/15. Appendix C details the
reasons for excluding each paper after the Title Stage.
Each of the eight studies reviewed varied in both the types and specific models of toothbrushes they used
as well as in the oral hygiene outcomes assessed. As previously mentioned, studies were not rejected
based on toothbrush specifics, given the vast number of different electric and manual toothbrushes
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available to fixed-orthodontic patients. However, the electric toothbrush interventions used in each study
fell under at least one of two categories: 1) ultrasonic, which relies on high-speed vibration for plaque
dislodgement, and 2) oscillating/rotating, which uses a high-speed rotating head for cleaning. It was
unclear from reviewing all of the studies whether either type offers a statistically significant advantage
over the other. As this was not the focus of the review, no conclusions were drawn with regard to type of
electric toothbrush. Additionally, all of the manual toothbrushes assessed as controls were conventional
toothbrushes except for the studies by Borutta et al17 and Thienpont et al2, in which orthodontic-specific
toothbrushes acted as controls for manoeuvring around orthodontic brackets.
All of the studies were of similar quality, having used randomized control trials, with almost all being
crossover. All of the crossover studies factored for subject learning biases by randomly dividing subjects
into different groups, each with a different sequence of treatments. This eliminates any chances of
subjects improving in brushing techniques over the study period. Furthermore, all of the studies ensured
that subjects were thoroughly instructed on proper brushing techniques with the treatment toothbrush
before each treatment period. Appendix D describes each of the studies reviewed including their
interventions used, controls used, outcomes, and the quality of each study based on scores and
classification.
Out of the eight studies reviewed comparing electric toothbrushes to manual toothbrushes for fixedorthodontic patients, four concluded that electric toothbrushes offered statistically significant benefits in
at least one area, three concluded that there was no statistical differences between brushes, and one
concluded that manual toothbrushes were better at most outcomes assessed. However, it is inaccurate to
draw conclusions based solely on the final conclusions of each study since each study looked at a subset
of outcomes that contribute to overall oral hygiene maintenance. Therefore, our review focuses on each
of the individual outcomes assessed within the studies. The outcomes looked at in the studies are
described below.
Plaque Index
Typically, plaque removal was only assessed on the buccal surface, where it was judged difficult for
patients to clean due to orthodontic brackets18. Although Costa et al’s 200712 study and Heasman et al’s14
1998 study reviewed examined plaque on both buccal and lingual surfaces. The removal of plaque was
assessed using different plaque indices among the different studies including the Quigley-Hein (QHI)
Plaque Index17, the Plaque Index Brackets (specifically for orthodontic brackets)19, and most commonly
the Silness and Loe Plaque Index. Studies reported the mean plaque index values for comparison
between treatments. Moreover, a baseline plaque index was measured and reassessed after specific time
periods. Prophylaxis treatment (i.e. cleaning and scaling) was administered in between crossover periods
as well as a washout period of at least one week. Only three of the studies concluded that the electric
toothbrush had statistically significant improvements over the manual toothbrushes5,12,17. Half of the eight
studies found no statistically significant difference in the plaque indices between the treatments2,14,18,20.
Anomalous to these findings was Trimpeneers et al’s study, which recorded better plaque indices for the
manual toothbrush19.
Gingival Index
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The Gingival Index (GI) is a measure of the severity of gingivitis a patient has and is usually scored by
measuring the amount of gingival inflammation21, also considering redness and bleeding22. All of the
studies that looked at GI used the Loe and Silness GI, except for Trimpeneers et al, which used a
Modified GI (accounting for orthodontic brackets)19. This latter study concluded that manual
toothbrushes yield better GI results than the electric toothbrushes tested3. The remaining four studies that
measured GI yielded no significant differences in GI between treatments2,14,18,20.
Interdental Bleeding and BOP
In addition to the GI, some studies looked specifically at bleeding outcomes as a separate measurement.
Clerehugh et al20 measured interdental bleeding via the Eastman Interdental Bleeding Index. This
involved noting the number of sites that bled within fifteen seconds of agitation of the interdental papilla
by a wooden wedge20. The result of this study was that the electric toothbrush had a statistically
significant reduction in bleeding compared with the manual toothbrush20. Borutta et al17, Trimpeeners et
al19, Ho et al5, and Thienpont et al2 all measured Bleeding on Probing (BOP), and only the latter
concluded that there was no significant difference in BOP, whereas the others found the electric
toothbrush to be better.
Other Outcomes
Costa et al’s studies12,18 and Ho et al’s study5 both assess bacterial counts. All of these studies observed
that the electric toothbrush reduced specific bacterial counts much more than the manual toothbrush,
however Costa et al’s 2010 study found no significant difference in the overall bacterial prevalence
between the different treatments18. Furthermore, both authors measured and compared gingival pocket
depths in their studies5,12. While Ho et al’s study found that the electrical toothbrush reduced pocket
depths much more5, Costa et al’s study found no difference with this same outcome12. One interesting
measurement was Borutta et al’s assessment by subject questionnaire, which found that 98.6% of
participants preferred the electric toothbrush over the manual17.
DISCUSSIO
Since the arrival of electric toothbrushes, their benefit relative to manual toothbrushes has been a topic of
consideration for consumers and researchers alike. Of particular interest is their ability to maintain a
healthy oral environment as part of a daily hygiene routine. With the incorporation of sophisticated
technologies and higher costs, one may expect electronic toothbrushes to be more effective than manual
toothbrushes. Surprisingly, it was shown that although rotation oscillation type of electronic brushes can
significantly reduce plaque and gingivitis in the general population, there are no statistically significant
differences between the effectiveness of electronic brushes and manual brushes23. However, this result
may not be conclusive for specific populations and this review is designed to address this issue on
orthodontic patients. This category of patient is of particular interest due to the presence of fixed oral
appliances which often increases the potential for food traps as well as interfering with brushing24.
Many factors contribute to the breakdown of oral health and plaque accumulation appears to play an
important role due to its associations with dental decay, gingivitis25. Toothbrushes, whether they are
electronic or manual, are designed as mechanical means to remove plaque and therefore this often
becomes the basis of comparison between toothbrushes. All nine studies in this review assessed the
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plaque removal ability of the toothbrushes on the buccal side of the teeth where the fixed orthodontic
brackets were located. Although different plaque indices were used for scoring among the studies, its
impact on the results should be minimum since the same index was used for comparison within each
study. All studies showed that electronic toothbrushes with proper instructions can significantly reduce
plaque level. However, only three out of the eight literatures were able to demonstrate that electronic
toothbrushes are significantly more effective in plaque removal when comparing to manual toothbrushes.
Additionally, among the four literatures that concluded no difference between electronic and manual
brushes, three of them evaluated two or more electronic brushes which further consolidate their results.
Therefore, it is clear that although electronic toothbrushes are effective in plaque reduction, their efficacy
is equivalent to manual toothbrushes.
Another parameter that most studies focused on was gingival health. The efficacy of the electronic and
manual toothbrushes were mainly assessed through the use of gingival index (GI) which is based on the
following characteristics of the gingiva: oedema, redness and bleeding22. The Eastman interdental
bleeding index or the bleeding on probing index was also evaluated as a supplementary measurement in
certain studies. Out of the five studies that used the gingival index, only one showed that patients who
used an electronic toothbrush resulted in a significant lower GI than those who used a manual toothbrush
while three studies showed no differences in efficacy. However, since only one study, by Clerehugh et
al20 used existing gingival bleeding as an inclusion criterion, it is difficult to draw a conclusive statement
based on these outcomes due to insufficient ground for baseline comparison. Furthermore, contradicting
outcomes were found in studies that assessed gingival bleeding on probing (BOP). Three of these four
studies showed that electronic toothbrushes are statistically more superior to manual toothbrushes in
having a lower mean incidence of BOP. This reduced incidence of BOP may be an attribute of electronic
toothbrushes being more effective in remove plaque just above the gingiva26. Nonetheless, it can be stated
that both electronic and manual toothbrushes have the same efficacy in maintaining gingival health except
gingival bleeding in which electronic toothbrushes perform more superiorly. In addition, based on the
study by Ho and Niederman5, which only comprised of orthodontic patients with existing gingivitis, it can
also be concluded that electric toothbrushes are more effective than manual toothbrushes in improving
periodontal health in patients with gingivitis.
The quality of the different studies did not play an important role in contributing to the conclusions due to
the strict exclusion criteria of this review. Most of the studies chosen utilized the crossover type of
randomized clinical trials design with sufficient wash out period that include a professional prophylaxis
which eliminates bias based on individual variations as well as cross-contamination between trails. The
random assignment of patients to randomized sequence of brush use is an influential factor because the
lack of randomization can often lead to order bias in RCT studies in which patient’s behaviour in the
latter trials are affected by the first trials. Also, the patients in all the studies are instructed with proper
oral hygiene instructions such as using specific kind of toothpaste, brushing technique, times and duration
of brushing, which are standardized throughout the studies. This, along with the refrainment from other
types of oral hygiene measures, further eliminates the variations between individuals. Furthermore, the
examiners in all but one study were blinded in order for unbiased evaluation and particularly in the two
studies done by Costa et al12,18 and Trimpeneers et al19, measures for intraexaminer reliability were
established.
Electric versus manual toothbrushes in the fixed orthodontic patient 10
In terms of bias, majority of the studies suffered from a common weakness which is the lack of large size
sample population. This may skew the results by increases the probability of a study in demonstrating no
significant difference between two trials. Another factor that may have affected the results of papers
reviewed is the Hawthorne Effect. Studies have shown that subjects’ behaviour can be influenced by the
knowledge that they are being observed, thus, giving rise to inaccurate data15. Awareness of their
participation in an experimental study and a desire to produce “good” results may have caused subjects to
unconsciously alter their oral hygiene habits, leading to erroneous results such as reduced plaque index or
gingival index scores. Finally, toothbrushing routines may have been subject to a novelty effect such that
there would be increased compliance at the beginning of the studies when patients were presented with
new toothbrushes. Consequently, efficacy scores recorded during initial visits would be artificially higher
than those from subsequent examinations. Such an effect was observed in a study by Clerehugh et al20,
which recorded higher second office visit gingival index scores for both the manual and electric brushes
during week eight of the intervention, compared to week four. As aforementioned, this review found that
there are minimal significant differences between the efficacy of electronic and manual brushes.
However, the removal of any potential novelty effects may reveal a significant difference between the two
groups. Despite the possibility of falsely augmented initial results, all studies included in this review were
conducted for a minimum of four weeks and this may have accounted for any novelty effects.
It is important to note that although the above conclusions are drawn based on statistics, their impact on
improvement of oral health may not be clinically relevant. Establishment of a threshold is difficult
because aside from the amount of plaque and gingival health, many other factors such as immune system,
diet also contribute to the overall health of the oral environment. A threshold level of 15% reduction on
both plaque index and gingival index compared to baseline has been suggested by the American Dental
Associations to result in significant improvement in oral health27. However, such threshold level is
arbitrary and is not well supported by studies. Furthermore, it should also be considered that all tests were
carried out in controlled settings in which the patients had to follow strict brushing instructions.
Consequently, this may limit the generalizability of results as they would apply to patients outside of an
experimental setting.
In addition to cleaning ability, toothbrush safety is also an important factor worth noting. Consideration
should be given to how conducive the brushes are to abrasion or recession, as this is an important factor in
the maintenance of good oral health. In their review of manual toothbrush safety versus electric
toothbrush safety, Van der Weijden et al found that, on average, less force was applied during power
toothbrush use in comparison to manual brushes28. Moreover, some of the current electric toothbrushes on
the market come equipped with pressure indicators that alert users when excessive force is being applied
during brushing28. This is of particular benefit to populations that may require greater supervision while
brushing to ensure that proper technique and force are being applied (e.g. mentally challenged, children,
elderly etc).
A previous review by Costa et al12 from 2007 examined a similar question in attempting to determine the
effectiveness of powered brushes compared to manual brushes. This study grouped orthodontic patients
with individuals with implants, and did not include other types of electric brushes12. Costa et al concluded
that sonic brushes are superior to manual brushes in removing plaque, along with improving gingival and
periodontal health12. Regarding plaque reduction and gingival indices, this review found that there is no
Electric versus manual toothbrushes in the fixed orthodontic patient 11
significant difference in the efficacy of manual and electric brushes12. This dissimilarity in conclusions
may be attributed to a difference in electric brush types studied. Costa et al12 studied only ultrasonic and
sonic brushes, whereas this review encompassed a wider range of power brush types. A more comparable
review by Kaklamos and Kalfas13 in 2008 attempted to determine the effectiveness of powered brushes
compared to manual brushes in orthodontic patients. In that study, the authors stated that insufficient
evidence was available to draw a conclusion on whether one brush type is more effective than the other13.
In terms of outcomes, the authors looked only at the effects of various toothbrushes on gingival
inflammation, particularly gingival index and gingival bleeding, when determining brush effectiveness13.
Also, stringent exclusion criteria resulted in only five papers being analyzed in the review. The criteria
used in this review allowed for the inclusion of nine articles. The greater number of papers analyzed,
acceptance of various electric brush types and outcomes (plaque index, bleeding on probing, gingival
index etc) permitted the authors to conclude that electric toothbrushes have an advantage over manual
brushes in bleeding on probing.
Another factor impacting toothbrush recommendation is cost. Upon browsing the current market, electric
toothbrush prices were found to range from $15.00 to upwards of $100.00, with refill heads costing from
$7.00 to $20.00. The price of a manual brush is appreciably less at approximately $5.00 each.
Consequently, electric brushes may not be recommended for all individuals as they have significantly
higher costs and only marginal benefits over manual brushes. However, power brushes may be
advantageous for certain populations that have increased difficulty in maintaining oral hygiene (e.g.
mentally challenged, elderly etc).
In evaluating plaque index, buccal and lingual tooth surfaces were analyzed, but interproximal areas were
excluded. Although accessing this area for plaque analysis may be challenging, further studies could be
implemented to determine if there is increased efficacy of either electric or manual toothbrushes on
interproximal plaque removal. As interproximal plaque is difficult to visualize and eliminate, identifying
a brush capable of maintaining oral hygiene in that area would facilitate home maintenance of oral
hygiene and may also potentially decreased the risk of interproximal caries.
Furthermore, a comparison of various specialized brush heads available should be conducted to determine
if there is any added benefit from the combined used of specific brush types and heads (e.g. orthodontic
brush heads with electric brushes). This would allow for more accurate conclusions to be drawn in
relation to the efficacy of electric or manual brushes in maintaining oral hygiene for populations with
unique needs.
In conclusion, electric toothbrushes are effective in reducing plaque index and gingival index scores but
their efficacy is the same as manual brushes. Power brushes, however, perform more superiorly in
reducing the incidence of bleeding on probing as compared to manual brushes. Given that it is unclear
whether these marginal improvements are clinically significant, it is uncertain whether the greater costs of
powered toothbrushes are justified. Accordingly, our recommendation is for orthodontic patients to
continue use of manual toothbrushes until stronger evidence is available to justify the higher costs of
electric toothbrushes. A certain subset of fixed orthodontic patients (i.e. impaired manual dexterity,
recessed gums) may derive the greatest benefits from powered toothbrushes.
Electric versus manual toothbrushes in the fixed orthodontic patient 12
Acknowledgements: The authors thank Dr. Ihab Suwwan and Dr. Amir Azarpazhooh at the University of Toronto
Faculty of Dentistry for their guidance and assistance throughout the production of this manuscript. We also thank
Maria Buda from the University of Toronto Dentistry Library for her assistance in our database searches.
Contributions: All 5 authors were equally involved in establishing the PICOC and objectives, in conducting the
electronic searches, and in reviewing and appraising the collected articles. Individual contributions included: Kerry
D’Costa—results, Ralph Dana—introduction and abstract, Gavin Ip and Eleanor Kong—discussion, Inna Vol—
methods.
Electric versus manual toothbrushes in the fixed orthodontic patient 13
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effectiveness of a counterrotational-action power toothbrush on plaque control in
orthodontic patients. Am J Orthod Dentofacial Orthop 1991;99(1):7-14.
2. Thienpont V, Dermaut LR, Van Maele G. Comparative study of 2 electric and 2 manual
toothbrushes in patients with fixed orthodontic appliances. Am J Orthod Dentofacial
Orthop 2001;120(4):353-60.
3. Schwaninger B, Vickers-Schwaninger N. Developing an effective oral hygiene program
for the orthodontic patient: Review, rationale, and recommendations. Am J Ortho
1979;75(4):447-452.
4. Rafe Z, Varmion A, Ashkenazi M. Comparative study of 3 types of toothbrushes in
patients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop
2006;130(1):92-5.
5. Ho HP, Niederman R. Effectiveness of the Sonicare sonic toothbrush on reduction of
plaque, gingivitis, probing pocket depth and subgingival bacteria in adolescent
orthodontic patients. J Clin Dent 1997;8:15-9.
6. Atack, NE, Sandy JR, Addy M. Periodontal and microbial changes associated with the
placement of orthodontic appliances: a review. J Periodontol 1996;67;78-85.
7. Boyd RL, Murray P, Robertson PB. Effect of rotary electric toothbrush versus manual
toothbrush on periodontal status during orthodontic treatment. Am J Orthod Dentofacial
Orthop 1989;96(4):342-7.
8. Diamanti-Kipioti A, Gusberti FA, Lang NP. Clinical and microbiological effects of fixed
orthodontic appliances. J Clin Periodontol 1987;14:326-333.
9. Paolantonio M, et al. Occurrence of Actinobacillus actinomycetemcomitans in patients
wearing orthodontic appliances: a cross-sectional study. J Clin Periodontol 1996;23:112118.
10. Trombeli L, Scabbia A, Griselli A, Zangari F, Calura G. Clinical evaluation of plaque
removal by counterrotational electric toothbrush in orthodontic patients. Quintessence
Int 1995;26(3):199-202.
11. Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, Glenny
AM, Shaw WC. Manual versus powered toothbrushing for oral health. Cochrane
Database of Systematic Reviews 2005;2,CD002281. DOI:
10.1002/14651858.CD002281.pub2.
12. Costa MR, Marcantonio RA, Cirelli JA. Comparison of manual versus sonic and
ultrasonic toothbrushes: a review. Int J Dent Hyg 2007;5(2):75-81.
13. Kaklamanos EG, Kalfas S. Meta-analysis on the effectiveness of powered toothbrushes
for orthodontic patients. Am J Orthod Dentofacial Orthop 2008;133:18&,e1–14.
14. Heasman P, Wilson Z, Macgregor I, Kelly P. Comparative study of electric and manual
toothbrushes in patients with fixed orthodontic appliances. Am J Orthod Dentofacial
Orthop 1998;114(1):45-9.
15. Fletcher, Fletcher and Wagner. Clinical epidemiology – the essentials. 3rd ed. 1996.
16. Sackett et al. Evidence-based medicine: how to practice and teach EBM. 1997.
17. Borutta A, Pala E, Fischer T. Effectiveness of a powered toothbrush compared with a
manual toothbrush for orthodontic patients with fixed appliances. Journal of Clinical
Dentistry 2002; 13(4):131-7.
Electric versus manual toothbrushes in the fixed orthodontic patient 14
18. Costa MR, Camilla da Silva V, Cirelli JA, Colombo APV, Miqui MN. Effects of
ultrasonic, electric, and manual toothbrushes on subgingival plaque composition in
orthodontically banded molars. Am J Orthod Dentofacial Orthop 2010;137:229-35.
19. Trimpeneers, LM, Wijgaerts, IA, Grognard NA, Dermaut LR, Adriaens PA. Effect of
electric toothbrushes versus manual toothbrushes on removal of plaque and periodontal
status during orthodontic treatment. Am J Orthod Dentofacial Orthop 1997; 11(5): 492497.
20. Clerehugh V, Williams P, Shaw WC, Worthington HV, Warren P. A practice-based
randomised controlled trial of the efficacy of an electric and a manual toothbrush on
gingival health in patients with fixed orthodontic appliances. J Dent 1998; 26: 633-639.
21. Welbury et al. Increase prevalence of dental caries and poor oral hygiene in juvenile
idiopathic arthritis. Oxford Journals – Rheumatology 2003; 42(12):1445-1451.
22. Benamghar L, Penaud J, Kaminsky P, ABT F, Martin J. Comparison of gingival index
and sulcus bleeding index as indicators of periodontal status. Bulletin WHO 1982;
60(1):147-151.
23. Deery C, Heanue M, Deacon S, Robinson PG, Walmsley AD, Worthington H, Shaw W,
Glenny A-M. The effectiveness of manual versus powered toothbrushes for dental health:
a systematic review. J Den 2004; 32:197-211.
24. Sukontapatipark W, El-Agroudi M, Selliseth NJ, Thunold K, Selvig KA. Bacterial
colonization associated with fixed orthodontic appliances. A scanning electron
microscopy study. Eu J Orthod 2001; 23:475-484.
25. Cancro LP, Fischman SL. The expected effect on oral health of dental plaque control
through mechanical removal. Perio 1995; 8:60-74.
26. Gugerli P, Secci G, Mombelli A. Evaluation of the benefits of using a power toothbrush
during the initial phase of periodontal therapy. J Perio 2007; 78(4):654-660.
27. Am Dent Assn Council on Scientific Affairs;1998.
28. Van der Weijden FA, Campbell SL, Dorfer CE, Gonzalez-Cabezas C, Slot DE. Safety of
oscillating-rotating powered brushes compared to manual toothbrushes: A systematic
review. J Periodontol 2011; 82:5-24.
Electric versus manual toothbrushes in the fixed orthodontic patient 15
APPEDIX A: CHECKLIST CRITERIA
Citation:
Checklist to Assess Evidence of Efficacy of Therapy or Prevention
____________________________________________________
1.
2.
3.
4.
5.
Was the study ethical?
Was a strong design used to assess efficacy?
Were outcomes (benefits and harms) validly and reliably measured?
Were interventions validly and reliably measured?
What were the results?
Was the estimate of the treatment effect beyond chance and relatively precise?
If the findings were “no difference” was the power of the study 80% or better
6. Are the results of the study valid?
• Was the assignment of patients to treatments randomised?
• Were all patients who entered the trial properly accounted for and
attributed at its conclusion?
i) Was loss to follow-up less than 20% and balanced between test and controls ___
ii) Were patients analysed in the groups to which they were randomised?
• Was the study of sufficient duration?
• Were patients, health workers, and study personnel “blind” to treatment?
• Were the groups similar at the start of the trial?
• Aside from the experimental intervention, were the groups treated equally?
• Was care received outside the study identified and controlled for
___
___
___
___
___
___
___
___
___
___
7. Will the results help in caring for your patients?
Were all clinically important outcomes considered?
Are the likely benefits of treatment worth the potential harms and costs?
___
___
___
___
___
Adapted from: Fletcher, Fletcher and Wagner. Clinical epidemiology – the essentials. 3rd ed. 1996, and
Sackett et al. Evidence-based medicine: how to practice and teach EBM. 1997
Electric versus manual toothbrushes in the fixed orthodontic patient 16
APPEDIX B: SEARCH STRATEGY
Search result from
PubMed
Keyword Search: (n=14)
MeSH Search: (n=61)
("orthodontics"[All fields] OR "braces"[All fields] OR
"brackets"[All fields]) AND ("electric"[All fields] OR
"oscillating"[All fields] OR "powered"[All fields]) AND
"toothbrush*"[All fields]
"Toothbrushing/instrumentation"[Me
sh] AND "Orthodontics"[Mesh]
Combined results + 1
Googlescholar article (n=76)
Removal of
duplicates (n = 11)
Initial Search (n=65)
Exclusion by title
screening (n = 28)
Eligible studies after Title
Stage (n=37)
Exclusion by abstract
screening (n = 19)
Eligible studies after Abstract
Stage (n=18)
Exclusion by full text
review of outcomes (n=6)
Eligible studies after Full-copy
Stage (n=12)
Final Inclusion of 8 studies
Exclusion by checklist
assessment and scoring
(n=4)
Electric versus manual toothbrushes in the fixed orthodontic patient 17
APPEDIX C: EXCLUDED ARTICLES
Authors
Bock C et al., 2010
Arici et al., 2007
Articles excluded and reasons for exclusion from evidence based review
Article Title
Reason for Exclusion
Plaque control effectiveness and handling of
interdental brushes during
multibracket treatment--a randomized clinical trial.
Comparison of different toothbrushing protocols in
poor-toothbrushing orthodontic
patients.
Sander et al., 2006
Dental care during orthodontic treatment with
electric toothbrushes.
Rafe et al., 2006
Comparative study of 3 types of toothbrushes in
patients with fixed orthodontic
appliances.
Sander et al., 2005
Dental care with manual toothbrushes during fixed
orthodontic treatment--a new
testing procedure.
Gheewalla et al.,
2002
Effects of three electric toothbrushes on orthodontic
bracket retention.
Pucher et al., 1999
The effectiveness of an ionic toothbrush in the
removal of dental plaque and
reduction on gingivitis in orthodontic patients.
Kiliçoğlu et al., 1997
Comparison of the effectiveness of two types of
toothbrushes on the oral hygiene
of patients undergoing orthodontic treatment with
fixed appliances.
Berglund et al., 1990
Effective oral hygiene for orthodontic patients.
Schätzle et al., 2010
In vitro tooth cleaning efficacy of electric
toothbrushes around brackets.
Schätzle et al., 2009
In vitro tooth cleaning efficacy of manual
toothbrushes around brackets.
García-Godoy et al.,
2007
Effect of manual and powered toothbrushes on
orthodontic bracket bond strength.
Hansen et al., 1999
Effect of brushing with sonic and counterrotational
toothbrushes on the bond
strength of orthodontic brackets.
Kaklamanos et al.,
2008.
Meta-analysis on the effectiveness of powered
toothbrushes for orthodontic
patients.
Costa et al., 2007
Comparison of manual versus sonic and ultrasonic
Data presented/study design does
not pertain to our topic of interest.
In Vitro Study
Review
Electric versus manual toothbrushes in the fixed orthodontic patient 18
toothbrushes: a review.
Boyd, 1997
Kossack et al., 2005
Clinical and laboratory evaluation of powered
electric toothbrushes: review of
the literature.
Plaque and gingivitis reduction in patients
undergoing orthodontic treatment with
fixed appliances-comparison of toothbrushes and
interdental cleaning aids. A
6-month clinical single-blind trial.
Heintze et al., 1996
Effectiveness of three different types of electric
toothbrushes compared with a
manual technique in orthodontic patients.
Jackson, 1991
Comparison between electric toothbrushing and
manual toothbrushing, with and
without oral irrigation, for oral hygiene of
orthodontic patients.
Wilcoxon et al., 1991
Trombeli et al., 1995
Boyd et al., 1994
Hickman et al., 2002
Boyd et al., 1989
The effectiveness of a counterrotational-action
power toothbrush on plaque control in orthodontic
patients
Clinical evaluation of plaque removal by
counterrotational electric toothbrush in
orthodontic patients.
Effect of rotary electric toothbrush versus manual
toothbrush on decalcification
during orthodontic treatment.
Inappropriate control
Did not meet checklist cut-off
Length of study inadequate (< 4
weeks)
Oral hygiene aids used
Powered vs. manual toothbrushing in fixed
appliance patients: a short term randomized control
trial
Effect of rotary electric toothbrush versus manual
toothbrush on periodontal
status during orthodontic treatment.
Van Venrooy et al.,
1985
Plaque removal with a new powered instrument for
orthodontic patients in fixed
appliances.
Hotz et al., 1984
Effect of different toothbrushes and tooth cleaning
technics on interdental
plaque removal on teeth with and without fixed
orthodontic appliances--an
experimental model.
Ohyama et al., 1976
Toothbrushing method for orthodontic patients.
Womack et al., 1968
Comparative cleansing efficiency of an electric and
a manual toothbrush in
orthodontic patients.
Does not meet year cut-off (1990)
Electric versus manual toothbrushes in the fixed orthodontic patient 19
Chia, 2008
Evidence not strong enough to advocate powered
toothbrushes over manual for orthodontic patients.
Commentary
APPEDIX D: EVIDECE BASED TABLE
Author &
Date
Population
Costa et n=21 (11 boys,
al., 2010
10 girls)
Age: 12-18y
(Mean
15.12+/- 1.7)
Required:
Healthy, fixed
applicance for
min 1 yr
Setting:
Sao Paulo
State
University
School of
Dentistry,
Brazil
Costa et n=21 (11 boys,
al., 2007
10 girls)
Age: 12-18y
(Mean
15.12+/- 1.7)
Intervention
(# studied)
Tx A:
Ultrasonic
toothbrush
(Ultrasonex
Ultima
Toothbrush)
Ultrasonic
Tx B: Electric
toothbrush
(Braun Oral B
3D Plaque
Remover)
rotating/
oscillating
Tx A:
Ultrasonic
toothbrush
(Ultrasonex
Ultima
Toothbrush)
Control
(# studied)
Outcomes
Plaque Index
Gingival Index
Other
(PI)
(GI)
Silness and Loe N/A
Bacterial counts (DNATx C:
PI:
DNA hybridization):
Manual
Tx A:
Tx B: Significant
toothbrush
decreases in T.forsythia
(Oral
B Significant
(p=0.043)
Model 30) reduction on
buccal
Bass
surfaces, esp.
Tx C: Significant
technique
around
decreases in S. noxia
brackets
(p=0.01), S. sanguinis
(not
(p=0.026), P.
statistically
melaninogenica
significant)
(p=0.012)
No PI values
stated
No significant difference
between the treatments
for overall bacteria
levels (among all
species).
Conclusions: No significant differences found among all three
treatments (i.e. no superior toothbrush). (p>0.05)
Tx C:
Silness and Loe Loe and Silness Pocket depth:
Manual
PI:
GI: no
no significant differences
toothbrush
Tx A:
significant
between Txs
(Oral
B Stastically
differences in
Model 30) significant
marginal
S. mutans counts:
Bass
reduction on bleeding
Tx A: statistically
Class.*,
Level**
Critical appraisal
Checklist for Strengths:
Evidence of RCT crossover; Txs run in
Therapy
different orders btwn
groups; consistent (all
Checklist
subjects brushed 3x/day
score:
for 2 min with same
12.5/15
toothpaste); adequate
study duration (1
Class: C
month); adequate
washout period (14
days); 3 groups with
Level
of different sequences to
Evidence: I
eliminate Hawthorne
Effect.
Weaknesses:
old (2007) PI and GI
values used for baseline;
examiners were not
blind.
Checklist for Strengths:
Evidence of RCT crossover; Txs run in
Therapy
different orders btwn
groups; both buccal and
Checklist
lingual surfaces
score: 11/15 assessed; examiners
Electric versus manual toothbrushes in the fixed orthodontic patient 21
Ultrasonic
Required:
Healthy, fixed
applicance for
min 1 yr
Setting:
Sao Paulo
State
University
School of
Dentistry,
Brazil
Borutta et n=80 (27
al., 2002
males, 53
females)
Age: 12-18y
(Mean 13.53)
Required:
Healthy (no
caries, no
diseases, no
antibiotics),
fixed ortho w/i
past 6 months,
at least 12
technique
Tx B: Electric
toothbrush
(Braun Oral B
3D Plaque
Remover)
rotating/
oscillating
Tx A: Electric
toothbrush
(Dentacontrol
Duo MH-700
powered
toothbrush
with 2 brush
heads:
Rotaclip and
Interdentaclip)
rotating/
oscillating
(2500
rotations/min
Tx B:
Manual
toothbrush
with ortho
head
(Ortho P35)
buccal surfaces between Txs
only (mean PI
% difference =
6.36) (p=0.007)
significant decreases
(p<0.05)
TxB: Statistically
significant decreases
(p<0.05)
No other
statistically
significant
differences in
PI between Txs.
Conclusions: Although none of the treatments were better at
reducing gingival inflammation, the ultrasonic toothbrush
was best at reducing plaque on buccal surfaces with
orthodontic brackets. S. mutans counts were significantly
reduced in both ultrasonic and electric toothbrushes.
Quigley-Hein
Sulcus Bleeding Index
(QHI) PI:
(SBI):
Mean PI were
Mean SBI were
statistically
statistically better in Tx
better in Tx A
A than for Tx B
than for Tx B in
throughout the study
all
(p=0.006 after 2 wks)
measurements
(p=0.024 after 4 wks)
throughout the
study
Preference
(p=0.0001)
Questionnaire: Of 76
subjects that completed
the study, 75 preferred
Tx A (p<0.05).
Conclusions: Tx A was better than the Tx B because it
blinded; intraexaminer
Class: B
reliability was
established; consistent
(all subjects brushed
Level
of 3x/day for 2 min with
Evidence: I
same toothpaste);
adequate study duration
(1 month); adequate
washout period (14
days)
Weaknesses:
Hawthorne Effect
Checklist for Strengths:
Evidence of RCT crossover; Txs run in
Therapy
different orders btwn
groups; good # of
Checklist
subjects; single blind;
score: 14/15 considered Hawthorn
Effect and novelty effect
Class: A
and ruled out both;
consistent (all subjects
brushed 2x/day for 3
Level of
min with same
Evidence: I
toothpaste); adequate
study duration (1
month); assessments
taken every 2wks;
Electric versus manual toothbrushes in the fixed orthodontic patient 22
brackets or
bands/arch
improved plaque index. The result is consistent with other
studies listed that found electric toothbrushes to be better
than manual toothbrushes.
, circular
angle of 60o)
Setting:
FriedrichSchillerUniversity of
Jena, Germany
Clerehugh n=84 (37
et
al., males and 47
1998
females)
Age: 10-20y
(all but 6
subjects were
<16)
Required:
Healthy, some
plaque (plaque
index 1.25) &
some gingival
bleeding (to
Tx A: Electric
toothbrush
(Braun Oral-B
Plaque
Remover (D5)
with specially
designed
orthodontic
brush head
OD5)
rotating/
oscillating
Tx B:
Manual
toothbrush
(Reach
Compact
Head
Medium)
Silness and Loe
PI:
Tx A vs.
baseline: 32%
reduction in PI.
(p<0.001)
Tx B vs.
baseline: 29%
reduction in PI.
(p<0.001)
No significant
difference
between Txs.
Loe and Silness
GI: No
statistically
significant
change in GI for
either Tx
compared to
baseline.
(Tx A: p=0.64)
(Tx B:
p=0.75)
Eastman Interdental
Bleeding Index:
Tx A vs. baseline: 12%
reduction. (p=0.004)
Tx B vs. baseline: No
statistically significant
reduction over study
duration. (p=0.65)
adequate washout
period (1 wk) with
professional prophy.
Weaknesses:
No mention/exclusion of
subjects not capable of
performing oral hygiene
instructions (e.g. manual
dexterity or mental
disabilities, etc.) nor
subjects with
periodontal disease; loss
of four subjects
Checklist for Strengths:
Evidence of RCT stratified parallel;
Therapy
Single
blind;
good
inclusion/exclusion
Checklist
criteria; good sample
score: 14/15 size (84), good study
duration
(8
wks);
Class: B
assessments taken every
4 wks; good washout
period; all subjects but
Level of
one submitted diary
Evidence: I
(showing compliance)
Weaknesses:
Electric versus manual toothbrushes in the fixed orthodontic patient 23
show
progress), full
arch upper
and lower
fixed
appliance
Conclusions: Tx A compared equally with Tx B on all
measurements except interdental bleeding, in which it was
proved better. This finding for interdental bleeding is
consistent with other studies listed that found electric
toothbrushes to be better than manual toothbrushes.
only assessed buccal
surfaces, not lingual;
Hawthorne Effect
Excluded: ppl
incapable of
performing
oral hygiene
instructions,
ppl with
periodontal
problems
Setting:
Leeds Dental
Institute, UK
Heasman n=60 (21
et
al., males, 39
1998
females)
Age: 12-16y
Required:
started ortho
treatment w/i
past 12
months, at
Tx A: Electric
toothbrush
(Braun Oral B
Plaque
Remover (D7)
with
dedicated
orthodontic
brush head
OD5-1)
rotating/
Tx C:
Oral B P35
Bass
and Charters
techniques
No statistically
significant
difference in
efficacy
at
decreasing PIs
at
buccal,
lingual,
interproximal
sites
No statistically N/A
significant
difference
in
gingival
bleeding
at
buccal, lingual,
interproximal
sites
Checklist for Strengths:
Evidence of RCT crossover; single
Therapy
blind; controlled for
toothpaste; good study
Checklist
duration (14 wks) with
score: 9.5/15 each Tx tested for 4 wks;
prophylaxis before use
Class: C
of each new brush;
assessed buccal, lingual,
interproximal areas
Level of
Electric versus manual toothbrushes in the fixed orthodontic patient 24
least 12
brackets/arch,
no onset of
periodontal
disease
Setting:
University of
Newcastle
upon Tyne, UK
Trimpene n=36 (17 boys,
ers et al., 19 girls)
1997
Age: 11y5m –
15y2m
oscillating
Tx B: Electric
toothbrush
(Dental Logic
HP550 with
regular head
HP5924)
Tx A: Electric
toothbrush
(Baush &
Lomb
Interplak)
Mean age
(boys: 12yr7m,
girls: 15yr2m)
Tx B: Electric
toothbrush
(Philips)
Required:
Systemically
healthy
Tx C: Electric
toothbrush
(Novitas
Rotadent)
Setting:
University of
Gent, Belgium.
Evidence: I
Weaknesses:
no washout (aside from
prophylaxis)
Conclusions: No significant differences found among all three
treatments (i.e. no superior toothbrush). (p>0.05)
Tx D:
Manual
multi-fluted
toothbrush
(Blend-aMed,
Proctor
&
Gamble)
PI: Tx D
performed
significantly
better than all
other Txs
(p = 0.06)
Modified GI: Tx
D
performed
significantly
better than all
other Txs
(p = 0.08)
Bleeding on Probing
Index
(BI):
Tx
B
performed significantly
better than all other Txs
(p = 0.10)
Plaque Index
brackets (PIb):
Tx D performed
significantly
better than all
other Txs
(p = 0.75)
Conclusions: Tx D was better than all other Txs, except for
bleeding on probing, which was best in Tx B.
Checklist for Strengths:
Evidence of RCT crossover; Txs run in
Therapy
different orders btwn
groups; single blind;
Checklist
good study duration
score: 11/15 (January 1992 – March
1993); 2 months
Class: E
duration for each brush;
no other oral hygiene
measures were allowed;
Level of
treatment by the same
Evidence: I
orthodontist which
minimized variability; 3
examiners, each scored
the same parameter on
all patients; consistent
(all subjects brush for 3
min)
Weaknesses:
Electric versus manual toothbrushes in the fixed orthodontic patient 25
Ho
HP, n=24
(12
Niederma males,
12
n R.,
females)
1997
Age: 11-17y
Required:
All
existing
overt gingivitis
and probing
pocket depths
>=3 mm, full
mouth fixed
ortho
Setting:
Harvard
School
Dental
Medicine,
Boston
of
Tx A:
Sonicare sonic
toothbrush
Ultrasonic
Tx B:
Oral B P35
Bass
technique
1 boy withdrew from
study; simple scoring
system which does not
provide details; no
unified brushing
technique
Significant
Tx A: Significant Mean Pocket Depth:
Checklist for Strengths:
decrease in
decrease in BOP Decreased in Tx B (6%) Evidence of RCT
parallel
study;
supragingival
but less than decrease in Therapy
measurements by singly
plaque
Tx A (29%). (p<0.001)
blinded
investigator;
reduction for
Checklist
adequate study duration
Tx A (57%) vs.
score: 13/15 (4 weeks); standardized
Bacteria:
Tx B (10%)
Tx A:
time for brushing with
(p<0.001)
Significant decrease in
Class: B
both groups
total gram negative
bacteria and total
Weaknesses:
subgingival bacteria
Level of
Oral hygiene instructions
(p<=0.05)
Evidence: I
were given by unblinded
investigator;
no
Tx B:
measurements
in
Increased total gram
between baseline and
negative bacteria
the final measurement;
Hawthorne Effect
Conclusions: Tx A found superior to Tx B in improving
periodontal health in patients with gingivitis.
Electric versus manual toothbrushes in the fixed orthodontic patient 26
Thienpont n=36 (18
et
al., males, 18
2001
females)
Age: 11y1m –
24y5m
(Mean 13.5y)
Required:
Healthy
Setting:
Department of
Orthodontics,
University of
Ghent,
Belgium
PI on brackets:
No significant
differences
between the 4
Txs.
No significant
differences
between the 4
Txs.
Bleeding on probing:
Checklist for Strengths:
No
significant Evidence of RCT crossover; single
differences between the Therapy
blind; adequate washout
4 Txs.
period; no extra oral
Checklist
hygiene measures
score:
allowed; consistent
10.5/15
(same brushing method,
same toothpaste,
Class: C
standardized brushing
time of 3 minutes twice
daily); single examiner
Level of
scored all teeth
Evidence: I
Tx A:
Electric
toothbrush
(Braun Oral-B
3D Plaque
Remover)
rotation/
oscillation
Tx C:
Manual
toothbrush
(Lactona
orthodontic
toothbrush)
Bass
technique
Tx B:
Electric
toothbrush
(PhilipsJordan HP
510)
rotation/
oscillation
Tx D:
Manual
toothbrush
(Oral-B
Advantage
Control Grip)
Bass
Conclusions: No difference in efficacy among the four
technique
different Txs.
PI on tooth:
Tx B had a
better
outcome on
the left side of
the mouth.
* Recommended grading for classification (modified from The Canadian Task Force on Preventive Health Care guidelines). The assigned
grade for each study was completed by comparing individual grades by two separate group members. Where differences in grading arose, a
third group member graded the study as well to reach a majority ruling.
CTFR- Canadian Task Force Recommendations
A- Good evidence to recommend the Clinical Preventive Action.
B- Fair evidence to recommend the Clinical Preventive Action.
C- Existing evidence is conflicting and does not allow making recommendation for or against use of the clinical preventive action, however other factors may
influence decisionmaking.
D- Fair evidence to recommend against the Clinical Preventive Action.
E- Good evidence to recommend against the Clinical Preventive Action.
I- Insufficient evidence (in quantity and/or quality) to make a recommendation, however other factors may influence decision-making.
Electric versus manual toothbrushes in the fixed orthodontic patient 27
**Level of evidence classifications (modified from The Canadian Task Force on Preventive Health Care guidelines).
I Evidence from randomized controlled trial(s)
II-1 Evidence from controlled trial(s) without randomization
II-2 Evidence from cohort or case-control analytic studies, preferably from more than one centre or research group
II-3 Evidence from comparisons between times or places with or without the interventions; dramatic results in uncontrolled experiments could be included
here
III Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert committees