ReviewThe effectiveness of manual versus powered toothbrushes for dental health: a systematic review
Introduction
Dental plaque is implicated in the aetiology of dental caries, gingivitis and periodontitis, therefore the removal of plaque is thought to play a key role in the prevention of these diseases.1 The relationship between plaque levels (oral hygiene) and periodontal disease is complex and not well understood. Similarly when teeth are brushed with fluoride toothpaste there is considerable evidence of a caries reduction.2 However, this reduction in caries levels is principally due to the action of fluoride in the toothpaste rather than brushing per se.3
Commercial powered (electric) toothbrushes were first introduced in the early 1960s,4., 5., 6., 7. although Frederick Wilhelm,8 a Swedish clockmaker, patented the earliest device in 1855. Powered brushes were first introduced with a back and forth action. Subsequent development has lead to the development of rotary action brushes and more recently higher frequency of vibration brushes.9., 10.
One study has shown that 36 months after purchase, 62% of people were still using their powered brush on a daily basis.11 The reported compliance level was high and was unrelated to any social factors of the population studied. Mechanical plaque removal with a manual toothbrush remains the primary method of maintaining good oral hygiene for the majority of the population.10 However, in the UK the volume of sales of powered toothbrushes has nearly doubled each year between 1999 and 2001.12
Despite the increasing interest in powered toothbrushes, their effectiveness in comparison to manual toothbrushes has not previously been evaluated through a systematic review of the literature. Systematic reviews of randomised controlled trials are seen as the gold standard for assessing the effectiveness of healthcare interventions. By following explicit, well-documented, scientific methodology they aim to provide an objective, comprehensive view of the research literature.
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. The removal of stain, prevention of calculus formation, dependability, adverse effects and cost were also considered.
The review was carried out in collaboration with the Cochrane Oral Health Group. Three of the authors (BS, DW and HW) have been involved in research in the area of this review funded by a powered toothbrush manufacturer (Braun) and therefore have potential conflicts of interest.
Section snippets
Inclusion criteria
To be included in the review a trial had to be a randomised controlled trial (RCT) comparing manual and powered brushes. Trials confined to comparing different types of powered or different types of manual brushes were excluded. Cross-over designs were eligible but split mouth designs were excluded as these were considered not to represent everyday use. Trials with subjects of any age were included but trials including individuals with special needs that would compromise their brushing ability
Results
The search identified 354 trials, 139 of which were excluded on the basis of the abstract. Full articles were obtained for the remaining 215 trials. From these trials, 152 proved ineligible and 36 had insufficient information to be included. A further 2 unpublished trials were also identified. Therefore, 29 trials fulfilled all inclusion criteria and had results that could be entered for meta-analysis. The principal reason for exclusion was the short duration of studies of less than 28 days.
Discussion
People brush their teeth for a number of reasons: to feel fresh and confident; to have a nice smile; to avoid bad breath and avoid disease. There is overwhelming evidence that toothbrushing reduces gingivitis.53 It may prevent periodontitis, although many factors as well as plaque are associated with periodontitis including tobacco usage and medical factors. Toothbrushing certainly prevents tooth decay if carried out in conjunction with fluoride toothpaste.3 These benefits occur whether the
Acknowledgments
Thanks are due to Sylvia Bickley, Trials Search Co-ordinator for the Oral Health Group for carrying out the searches for the review, Liz Asbridge for administration of the review, co-ordination of databases and location of articles for the review. Thanks also go to Emma Tavender for making available her expertise in the field of systematic reviews, Revman 4.1 and for copy editing the final draft of the Cochrane Review. For help with the translations of foreign papers our thanks go to Selva Can
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