Elsevier

Journal of Dentistry

Volume 32, Issue 3, March 2004, Pages 197-211
Journal of Dentistry

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

https://doi.org/10.1016/j.jdent.2003.11.006Get rights and content

Abstract

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.

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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