Powered versus manual toothbrushing for oral health

  • Review
  • Intervention

Authors


Abstract

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 (I2 = 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 (I2 = 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.

Résumé scientifique

Comparaison des brosses à dents électriques et manuelles pour la santé bucco-dentaire

Contexte

L'élimination de la plaque dentaire peut jouer un rôle essentiel dans l’entretien de la santé bucco-dentaire. Il existe des preuves contradictoires sur les mérites relatifs des brosses à dents électriques et manuelles dans l’obtention de ce résultat. La présente revue est une mise à jour d'une revue Cochrane publiée pour la première fois en 2003 et précédemment mise à jour en 2005.

Objectifs

Comparer les brosses à dents manuelles et électriques dans la pratique quotidienne, utilisées par les personnes de tous âges, en termes d’élimination de la plaque dentaire, de santé des gencives, de décoloration et de tartre, de fiabilité, d’effets indésirables et de coût.

Stratégie de recherche documentaire

Nous avons effectué des recherches dans les bases de données électroniques suivantes : registre des essais du groupe Cochrane sur la santé bucco-dentaire (jusqu'au 23 janvier 2014), registre Cochrane des essais contrôlés (CENTRAL) (Bibliothèque Cochrane 2014, numéro 1), MEDLINE via OVID (de 1946 au 23 janvier 2014), EMBASE via OVID (de 1980 au 23 janvier 2014) et CINAHL via EBSCO (de 1980 au 23 janvier 2014). Nous avons recherché des essais en cours dans le registre des essais des US National Institutes of Health (NIH) et le système d'enregistrement des essais cliniques de l'OMS. Aucune restriction de langue ou de date de publication n’a été posée pour les recherches dans les bases de données électroniques.

Critères de sélection

Essais contrôlés randomisés portant sur au moins quatre semaines de brossage des dents sans surveillance avec une brosse à dents électrique ou manuelle à des fins de santé bucco-dentaire, chez les enfants et les adultes.

Recueil et analyse des données

Nous avons utilisé des procédures méthodologiques standard prévues par la Collaboration Cochrane. Des modèles à effets aléatoires ont été utilisés à condition qu'au moins quatre études soient incluses dans la méta-analyse, et des modèles à effets fixes dans le cas contraire. Les données ont été classées en données à court terme (un à trois mois) et à long terme (plus de trois mois).

Résultats principaux

Cinquante-six essais remplissaient les critères d'inclusion ; 51 essais portant sur 4 624 participants ont fourni des données pour une méta-analyse. Cinq essais étaient à faible risque de biais, cinq à haut risque et 46 avaient un risque de biais incertain.

Il existe des preuves de qualité modérée de ce que les brosses à dents électriques apportent un bénéfice statistiquement significatif par rapport aux brosses à dents manuelles en ce qui concerne la réduction de la plaque dentaire, aussi bien à court terme (différence moyenne standardisée (DMS) -0,50 (intervalle de confiance (IC) à 95 % de -0,70 à -0,31) ; 40 essais, n = 2 871) qu’à long terme (DMS de -0,47 (IC à 95 % de -0,82 à -0,11 ; 14 essais, n = 978). Ces résultats correspondent à une réduction de 11 % de la plaque dentaire pour l’indice Quigley Hein (Turesky) sur le court terme et de 21 % à long terme. Les deux méta-analyses ont montré des niveaux élevés d'hétérogénéité (I2 = 83 % et 86 % respectivement) qui n'étaient pas explicables par les différents sous-groupes par types de brosse à dents électrique.

En ce qui concerne la gingivite, il existe des preuves de qualité modérée de ce que les brosses à dents électriques apportent là encore un bénéfice statistiquement significatif par rapport aux brosses manuelles, à la fois à court terme (DMS de -0,43 (IC à 95 % de -0,60 à -0,25) ; 44 essais, n = 3 345) et à long terme (DMS de -0,21 (IC à 95 % de -0,31 à -0,12) ; 16 essais, n = 1 645). Cela correspond à une diminution de 6 % et 11 % de la gingivite selon les index de Löe et de Silness, respectivement. Les deux méta-analyses ont montré des niveaux élevés d'hétérogénéité (I2 = 82 % et 51 % respectivement) qui n'étaient pas explicables par les différents sous-groupes de types de brosse à dents électrique.

Le nombre d'essais était variable pour chaque type de brosses à dents électriques : à mouvement latéral (10 essais), à oscillation en sens inverse (cinq essais), à rotation-oscillation (27 essais), à mouvement circulaire (deux essais), à ultrasons (sept essais), ioniques (quatre essais) et de type inconnu (cinq essais). Le corpus de preuves le plus important a été recueilli pour les brosses à rotation-oscillation, qui ont donné une réduction statistiquement significative de la plaque dentaire et de la gingivite dans les deux délais d’évaluation définis.

Conclusions des auteurs

Les brosses à dents électriques réduisent davantage la plaque dentaire et la gingivite qu’un brossage manuel, à court et long terme. L'importance clinique de ces résultats reste incertaine. Le respect des directives méthodologiques et une meilleure standardisation de la conception des études seraient bénéfiques à la fois pour les futurs essais et pour les méta-analyses.

Le coût, la fiabilité et les effets secondaires n'ont pas été systématiquement rapportés. Les effets secondaires rapportés étaient localisés et transitoires.

Resumo

Escova de dente elétrica comparada com escova comum para a saúde bucal

Introdução

A remoção da placa bacteriana é fundamental para a manutenção da saúde bucal. As evidências são conflitantes quanto aos benefícios da escovação manual e elétrica na remoção da placa. Esta é a segunda atualização de uma revisão Cochrane publicada pela primeira vez em 2003, e que já foi atualizada em 2005.

Objetivos

Comparar as escovas de dente manuais e elétricas no uso no dia a dia, por pessoas de qualquer idade, em relação à remoção de placa, à saúde da gengiva, coloração dental e cálculos, confiabilidade, eventos adversos e custos.

Métodos de busca

Nós realizamos buscas nas seguintes bases de dados eletrônicas: Cochrane Oral Health Group’s Trials Register (até 23 de janeiro de 2014), Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library 2014, Issue 1), MEDLINE via OVID (desde 1946 a 23 de janeiro de 2014), EMBASE via OVID (desde 1980 até 23 de janeiro de 2014) e CINAHL via EBSCO (desde 1980 até 23 de janeiro de 2014). Procuramos por estudos em andamento fazendo buscas nas plataformas de registros de ensaios clínicos US National Institutes of Health Trials Register e WHO Clinical Trials. Não houve restrições de idioma ou data de publicação.

Critério de seleção

Foram incluídos ensaios clínicos randomizados com duração de pelo menos quatro semanas de escovação elétrica não supervisionada versus escovação manual, para a saúde bucal de crianças e adultos.

Coleta dos dados e análises

Utilizamos os procedimentos metodológicos padrão da Colaboração Cochrane. Usamos modelos de efeito randômico quando havia quatro ou mais estudos incluídos na metanálises; caso contrário, usamos os modelos de efeito fixo. Os dados foram classificados como de curto prazo (um a três meses) e de longo prazo (mais do que três meses).

Principais resultados

Um total de 56 estudos preencheram os critérios de inclusão; 51 estudos envolvendo 4.624 participantes contribuíram com dados para metanálise. O risco de viés foi considerado incerto em 46 estudos, baixo em 5 estudos e alto em 5 estudos.

Houve evidência de qualidade moderada de que escovas elétricas, em comparação com as escovas manuais, têm efeito benéfico estatisticamente significante em relação à redução de placa bacteriana tanto em curto prazo (diferença média padronizada, DMP, -0,50; intervalo de confiança de 95%, 95% CI, de -0,70 a -0,31; 40 estudos, n = 2.871) como no longo prazo (DMP -0,47, 95% CI -0,82 a -0,11; 14 estudos, n = 978). Esses resultados correspondem a uma redução de placa da ordem de 11% no curto prazo e 21% a longo prazo, segundo o índice Quigley Hein (Turesky). As duas metanálises tiveram bastante heterogeneidade (I2 = 83% e 86%, respectivamente), que não foi explicada pelos diferentes subgrupos de tipos de escovas elétricas.

Em relação à gengivite, houve evidência de qualidade moderada de que as escovas elétricas, em comparação com as escovas manuais, promovem benefício estatisticamente significante tanto em curto prazo (DMP -0,43; 95% CI -0,60 a -0,25; 44 estudos, n = 3.345) como no longo prazo (DMP -0,21 95% CI -0,31 a -0,12; 16 estudos, n = 1.645). Isso corresponde a uma redução de gengivite de 6% e 11%, respectivamente, segundo o índice Löeand Silness. As duas metanálises tiveram bastante heterogeneidade (I2 = 82% e 51%, respectivamente) que não foi explicada pelos diferentes subgrupos de tipo de escova elétrica.

O número de estudos para cada tipo de escova elétrica variou: movimento de vai e vem lateral (10 estudos), rotação contrária (5 estudos), rotação oscilante (27 estudos), circular (2 estudos), ultrassônica (7 estudos), iônica (4 estudos) e sem detalhes (5 estudos). O maior corpo de evidências foi para as escovas com rotação oscilante, mostrando uma redução estatisticamente significante da placa e da gengivite nos dois períodos em que esses desfechos foram medidos.

Conclusão dos autores

O uso de escova elétrica, comparada com escova manual, reduz mais a placa e a gengivite tanto no curto como no longo prazo. A importância clínica desses achados permanece incerta. Estudos futuros devem procurar seguir as diretrizes metodológicas e padronizar melhor seus desenhos, para melhorar tanto os próprios estudos primários como as futuras metanálises.

O custo, a reprodutibilidade e os efeitos adversos foram relatados de maneira inconsistente nos estudos existentes. Todos os eventos adversos relatados nos estudos incluídos nesta revisão foram localizados e apenas transitórios.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Maíra Tristão Parra)

Plain language summary

Powered/electric toothbrushes compared to manual toothbrushes for maintaining oral health

Review question

This review has been conducted to assess the effects of using a powered (or 'electric') toothbrush compared with using a manual toothbrush for maintaining oral health.

Background

Good oral hygiene, through the removal of plaque (a sticky film containing bacteria) by effective toothbrushing has an important role in the prevention of gum disease and tooth decay. Dental plaque is the primary cause of gingivitis (gum inflammation) and is implicated in the progression to periodontitis, a more serious form of gum disease that affects the tissues that support the teeth. The build up of plaque can also lead to tooth decay. Both gum disease and tooth decay are the primary reasons for tooth loss.

There are numerous different types of powered toothbrushes available to the public, ranging in price and mode of action. Different powered toothbrushes work in different ways (such as moving from side to side or in a circular motion). Powered toothbrushes also vary drastically in price. It is important to know whether powered toothbrushes are more effective at removing plaque than manual toothbrushes, and whether their use reduces the inflammation of the gums (gingivitis) and prevents or slows the progression of periodontitis.

Study characteristics

Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 23 January 2014. It includes 56 studies published from 1964 to 2011 in which 5068 participants were randomised to receive either a powered toothbrush or a manual toothbrush. Majority of the studies included adults, and over 50% of the studies used a type of powered toothbrush that had a rotation oscillation mode of action (where the brush head rotates in one direction and then the other).

Key results

The evidence produced shows benefits in using a powered toothbrush when compared with a manual toothbrush. There was an 11% reduction in plaque at one to three months of use, and a 21% reduction in plaque when assessed after three months of use. For gingivitis, there was a 6% reduction at one to three months of use and an 11% reduction when assessed after three months of use. The benefits of this for long-term dental health are unclear.

Few studies reported on side effects; any reported side effects were localised and only temporary.

Quality of the evidence

The evidence relating to plaque and gingivitis was considered to be of moderate quality.

Laički sažetak

Usporedba običnih i električnih zubnih četkica za održavanje zdravlja usne šupljine

Istraživačko pitanje

Napravljen je Cochrane sustavni pregled kako bi se procijenio učinak korištenja električnih četkica za zube naspram običnih (manualnih) četkica za zube za održavanje zdravlja usne šupljine.

Dosadašnje spoznaje

Dobra higijena usne šupljine, koja se postiže uklanjanjem plaka sa zubi (ljepljivih naslaga koje sadrže bakterije) učinkovitim četkanjem ima važnu ulogu u sprječavanju bolesti desni i propadanja zubi. Zubni plak je glavni uzrok gingivitisa (upale desni) i uključen je u nastanak periodontitisa, ozbiljnije bolesti desni koja zahvaća tkiva koja podupiru zub. Stvaranje naslaga plaka također dovodi do propadanja zubiju. Bolesti desni i propadanje zubi glavni su razlozi gubitka zubala.

Postoje brojne vrste električnih četkica, različite cijene i načina rada. Različite električne četkice rade na različite načine, primjerice neke se kreću s jedne na drugu stranu, ili se vrte ukrug. Električne četkice su također mnogo skuplje. Važno je znati da li električne četkice učinkovitije uklanjaju plak nego obične četkice, kao i to da li smanjuju upalu desni (gingivitis) i da li sprječavaju ili usporavaju napredovanje periodontitisa.

Obilježja studija

Autori okupljeni u Cochrane uredničkoj skupini za oralno zdravlje (engl. Cochrane Oral Health Group) napravili su analizu dostupnih studija i u ovom sustavnom pregledu predstavili dokaze iz literature dostupne do 23. siječnja 2014. Sustavni pregled uključuje 56 studija obavljenih između 1964. i 2011., u koje je bilo uključeno 5068 ispitanika, koji su četkali zube električnom ili običnom četkicom. Većina studija uključila je odrasle ispitanika, a preko 50% studija koristilo je električne četkice koje imaju rotirajuće i oscilacijske kretnje (kod kojih se glava četkice okreće malo u jednom pa malo u drugom smjeru).

Ključni rezultati

Pronađeni dokazi pokazuju da je bolje koristiti električnu nego običnu četkicu. Dokazano je 11%-tno smanjenje plaka u razdoblju od jednog do tri mjeseca te 21% smanjenje plaka kad je procijenjeno nakon 3 mjeseca korištenja. Za gingivitis je uočeno 6%-tno smanjenje u razdoblju od 1-3 mjeseca, a 11% smanjenje nakon 3 mjeseca korištenja. Učinci na dugoročno zdravlje zubala nisu jasni.

Malo je studij aopisalo nuspojave; kad su i opisane, nuspojave su bile lokalne i privremene.

Kvaliteta dokaza

Procijenjeno je da dokazi koji se odnose na plak i gingivitis imaju umjerenu kvalitetu.

Bilješke prijevoda

Cochrane Hrvatska
Prevela: Livia Puljak
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Résumé simplifié

Comparaison des brosses à dents électriques et manuelles pour l’entretien de la santé bucco-dentaire

Question de la revue

Cette revue a été menée afin d'évaluer les effets du brossage des dents avec une brosse à dents électrique (ou « à moteur ») par rapport à une brosse à dents manuelle pour l’entretien de la santé bucco-dentaire.

Contexte

En éliminant la plaque dentaire (un film collant contenant des bactéries) par un brossage des dents efficace, une bonne hygiène bucco-dentaire joue un rôle important dans la prévention des affections des gencives et de la carie dentaire. La plaque dentaire est la principale cause de la gingivite (une inflammation des gencives) et est impliquée dans la progression vers la parodontite, une forme plus grave de maladie des gencives affectant les tissus qui soutiennent les dents. L'accumulation de plaque dentaire peut également entraîner des caries dentaires. Les maladies gingivales et la carie dentaire sont les principales raisons de perte de dents.

Il existe sur le marché de nombreux types différents de brosses à dents électriques, dans un large éventail de prix. Elles peuvent fonctionner selon différents modes d'action (par exemple selon un mouvement latéral ou circulaire) et leur prix est également très variable. Il est important de savoir si les brosses à dents électriques sont plus efficaces pour éliminer la plaque dentaire que les brosses manuelles, et si leur utilisation réduit l'inflammation des gencives (gingivite) et prévient ou ralentit la progression de la parodontite.

Caractéristiques de l'étude

Des auteurs du groupe Cochrane sur la santé bucco-dentaire ont mené cette revue des études existantes et les preuves sont à jour au 23 janvier 2014. La revue inclut 56 études publiées entre 1964 et 2011, dans lesquelles 5 068 participants ont été randomisés pour recevoir soit une brosse à dents électrique, soit une brosse à dents manuelle. La majorité des études inclut des adultes, et plus de 50 % des études ont utilisé un type de brosse à dents électrique agissant par rotation et oscillation (la tête de la brosse tourne dans un sens, puis dans l'autre).

Principaux résultats

Les preuves produites montrent un effet bénéfique de l'utilisation d'une brosse à dents électrique par rapport à une brosse à dents manuelle. Il y a eu une réduction de 11 % de la plaque après un à trois mois d'utilisation, et une réduction de 21 % lorsque l’élimination de la plaque dentaire était évaluée après trois mois d'utilisation. Pour la gingivite, il y a eu une réduction de 6 % au bout d'un à trois mois d'utilisation et de 11 % après trois mois. Les bénéfices que cela peut apporter pour la santé dentaire à long terme sont imprécis.

Peu d'études ont rendu compte des effets secondaires ; les effets secondaires rapportés étaient localisés et transitoires.

Qualité des preuves

Les preuves relatives à la plaque dentaire et à la gingivite ont été considérées comme de qualité modérée.

Notes de traduction

Traduit par: French Cochrane Centre 13th October, 2014
Traduction financée par: Financeurs pour le Canada : Instituts de Recherche en Santé du Canada, Ministère de la Santé et des Services Sociaux du Québec, Fonds de recherche du Québec-Santé et Institut National d'Excellence en Santé et en Services Sociaux; pour la France : Ministère en charge de la Santé

Резюме на простом языке

Механизированные/электрические зубные щетки в сравнении с ручными зубными щетками для поддержания здоровья полости рта

Вопрос обзора

Этот обзор был проведен для оценки эффективности использования механизированной (или 'электрической') зубной щетки в сравнении с использованием ручной (обычной) зубной щетки для поддержания здоровья полости рта.

Актуальность

Хорошая гигиена полости рта путем удаления зубного налета (липкая пленка, содержащая бактерии) эффективной чисткой зубов играет важную роль в предотвращении заболеваний десен и кариеса зубов. Зубной налет является главной причиной гингивита (воспаление десен) и участвует в его прогрессировании в пародонтит, более серьезную форму заболевания десен, которое влияет на ткани, поддерживающие зубы. Накопление зубного налета может также привести к кариесу зубов. Оба фактора - и заболевание десен, и кариес зубов, являются основными причинами потери зубов.

Есть множество различных типов механизированных зубных щеток, доступных для населения, различающихся по цене и способу действия. Различные механизированные зубные щетки работают по-разному (например, перемещение из стороны в сторону или круговое движение). Механизированные зубные щетки также сильно различаются по цене. Важно знать, являются ли электрические зубные щетки более эффективными для удаления налета, чем ручные зубные щетки, и снижает ли их использование воспаление десен (гингивит) и предотвращает или замедляет ли прогрессирование пародонтита.

Характеристика исследований

Авторы из Кокрейновской Группы Здоровья Полости Рта выполнили этот обзор существующих исследований; доказательства актуальны по 23 января 2014. Он включает 56 исследований, опубликованных с 1964 по 2011, в которых 5068 участников были рандомизированы для применения либо электрической зубной щетки, либо ручной зубной щетки. Большинство исследований включали взрослых людей, и более чем в 50% исследований использовался тип механизированной зубной щетки, которая имела вращательно-колебательный способ действия (при котором головка щетки вращается в одном направлении, а затем в другом).

Основные результаты

Полученные доказательства показывают пользу от использования электрической зубной щетки при сравнении с ручной зубной щеткой. Было выявлено 11%-е уменьшение зубного налета при использовании электрической зубной щетки от одного до трех месяцев, и уменьшение зубного налета на 21%, когда оценивали (состояние) после трех месяцев применения. Гингивит: наблюдалось его уменьшение на 6% при использовании (электрической зубной щетки) от одного до трех месяцев, и на 11%, когда оценивали (состояние) после трех месяцев применения. Польза этого для долгосрочного здоровья зубов неясна.

В нескольких исследованиях сообщалось о побочных эффектах; любые побочные эффекты были локальными и только временными.

Качество доказательств

Доказательства, касающиеся налета и гингивита, были оценены как доказательства среднего качества.

Заметки по переводу

Перевод: Абакумова Татьяна Рудольфовна. Редактирование: Зиганшина Лилия Евгеньевна. Координация проекта по переводу на русский язык: Казанский федеральный университет. По вопросам, связанным с этим переводом, пожалуйста, свяжитесь с нами по адресу: lezign@gmail.com

Laienverständliche Zusammenfassung

Elektrische Zahnbürsten im Vergleich mit Handzahnbürsten zur Erhaltung der Mundgesundheit

Fragestellung

Dieser Review wurde durchgeführt, um die Wirkung einer elektrischen Zahnbürste im Vergleich zu einer Handzahnbürste bei der Erhaltung der Mundgesundheit zu bewerten.

Hintergrund

Eine gute Mundhygiene, also die Entfernung des klebrigen, bakterienhaltigen Zahnbelags (Plaque) durch wirksames Zähneputzen, spielt eine wichtige Rolle bei der Vorbeugung gegen Zahnfleischerkrankungen und Zahnfäule (Karies). Plaque ist die Hauptursache für Zahnfleischentzündung (Gingivitis) und spielt auch eine Rolle in der Entwicklung von Parodontitis, einer schwerwiegenderen Zahnfleischerkrankung, die den Zahnhalteapparat betrifft. Die Ansammlung von Plaque kann auch zu Karies führen. Zahnfleischerkrankungen und Karies sind die Hauptursachen für Zahnverlust.

Es sind zahlreiche Arten von elektrischen Zahnbürsten auf dem Markt, die sich in Preis und Funktionsweise voneinander unterscheiden. Verschiedene Modelle elektrischer Zahnbürsten arbeiten unterschiedlich (z. B. mit seitlichen oder kreisförmigen Bewegungen). Auch bestehen bei elektrischen Zahnbürsten große Preisunterschiede. Es ist wichtig zu wissen, ob elektrische Zahnbürsten wirksamer Plaque entfernen als Handzahnbürsten und ob ihr Gebrauch Entzündungen des Zahnfleisches (Gingivitis) verringert und das Voranschreiten von Parodontitis verhindert oder verzögert.

Studienmerkmale

Autoren der Cochrane Oral Health Group führten diesen Review bestehender Studien durch, die Evidenz ist auf dem Stand vom 23. Januar 2014. Eingeschlossen wurden 56 Studien von 1964 bis 2011, in denen insgesamt 5068 Teilnehmern nach dem Zufallsprinzip entweder eine elektrische oder eine Handzahnbürste zugeteilt wurde. Der Großteil der Studien wurde mit Erwachsenen durchgeführt und in mehr als 50 % der Studien kam eine elektrische Zahnbürste mit einer rotierend-oszillierenden Funktionweise zur Anwendung, bei der sich also der Bürstenkopf abwechselnd in die eine und in die andere Richtung dreht.

Hauptergebnisse

Die Evidenz zeigt einen Nutzen durch die Verwendung einer elektrischen Zahnbürste im Vergleich zu einer Handzahnbürste. Es wurde eine Verminderung der Plaque um 11 % nach ein bis drei Monaten Gebrauch festgestellt und eine Verminderung von 21 % nach einem Einsatz von über drei Monaten. Gingivitis ging nach ein bis drei Monaten um 6 % zurück und nach über drei Monaten um 11 %. Der Nutzen für die langfristige Zahngesundheit ist nicht eindeutig.

Wenige Studien berichteten über Nebenwirkungen; alle berichteten Nebenwirkungen waren örtlich begrenzt und vorübergehend.

Qualität der Evidenz

Die Qualität der Evidenz zu Plaque und Gingivitis wurde als moderat bewertet.

Anmerkungen zur Übersetzung

S. Schmidt-Wussow, freigegeben durch Cochrane Schweiz.

Resumo para leigos

Escovas de dentes elétricas comparadas com escovas manuais para preservar a saúde da boca

Pergunta da revisão

Esta revisão foi conduzida para avaliar os efeitos de se usar a escova de dentes elétrica em comparação com a escova de dente comum (manual) para preservar a saúde da boca (oral).

Introdução

A boa higiene oral, com uma escovação bem feita que remove a placa bacteriana (um filme grudento que contém bactérias), é importante para prevenir as doenças das gengivas e as cáries dentárias. A placa bacteriana é a principal causa de gengivite (inflamação de gengiva) e está envolvida na progressão da gengivite para periodontite, uma forma mais grave de doença gengival que afeta os tecidos que dão sustentação ao dentes (por exemplo, os ossos). A placa também pode levar a cárie dentária. As doenças das gengivas e as cáries são os principais responsáveis pela perda dos dentes.

Existem diversos tipos de escovas de dentes elétricas disponíveis para o público, variando em preço e modo de ação. Por exemplo, elas podem fazer movimentos de vaivém lateral ou então movimentos circulares. O preço das escovas elétricas também varia bastante. É importante saber se as escovas elétricas são mais efetivas do que as escovas comuns (manuais) para remover a placa, e se o seu uso reduz a inflamação das gengivas (gengivite) e previne ou diminui a progressão dessa inflamação para a periodontite.

Características do estudo

Os autores do Grupo de Saúde Oral da Cochrane realizaram esta revisão de estudos existentes e a evidência está atualizada até 23 de janeiro de 2014. A revisão inclui 56 estudos publicados desde 1964 até 2011, nos quais 5.068 participantes foram randomizados (colocados em diferentes grupos através de sorteio) para receber uma escova elétrica ou uma escova manual. A maioria dos estudos incluiu adultos, e mais de 50% dos estudos usaram um tipo de escova elétrica que fazia movimentos alternados de rotação (rotação oscilante), em que a cabeça da escova girava em uma direção e depois em outra.

Resultados principais

A evidência mostra que existem benefícios em usar a escova elétrica em comparação com a escova manual. Houve redução de 11% na placa bacteriana medida entre um e três meses de uso, e redução de 21% após três meses de uso. Houve redução de 6% dos casos de gengivite em um a três meses de uso e redução de 11% quando a avaliação foi feita após três meses de uso. Os benefícios disso em longo prazo para a saúde dental foram incertos.

Poucos estudos relataram efeitos adversos e, quando relatados, eles foram locais e transitórios.

Qualidade da evidência

A evidência sobre placa e gengivite foi considerada de qualidade moderada.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Maíra Tristão Parra)

Ringkasan bahasa mudah

Berus gigi letrik berbanding berus gigi manual untuk mengekalkan kesihatan gigi dan mulut

Soalan ulasan

Ulasan ini dibuat untuk menilai kesan penggunaan berus gigi letrik berbanding berus gigi manual untuk mengekalkan kesihatan gigi dan mulut.

Latarbelakang

Kesihatan gigi dan mulut yang baik, melalui pembuangan plak (lapisan melekit yang mengandungi bakteria) dengan memberus gigi secara berkesan, mempunyai peranan penting dalam pencegahan penyakit gusi dan kerosakan gigi.Plak gigi adalah penyebab utama gingivitis (keradangan gusi) dan berkait dengan punca periodontitis, satu bentuk penyakit gusi yang serius yang mempengaruhi tisu penyokong gigi.Pengumpulan plak juga boleh menyebabkan kerosakan gigi.Kedua-dua penyakit gusi dan kerosakan gigi merupakan penyebab utama kehilangan gigi.

Terdapat pelbagai jenis berus gigi letrik untuk kegunaan umum dalam pelbagai harga dan cara tindakan.Berus gigi berkuasa bertindak dalam berbagai cara (misalnya pergerakan sisi atau pergerakan bulatan). Berus gigi letrik juga berbeza dari segi harga.Penting untuk mengetahui sama ada berus gigi letrik adalah lebih berkesan dalam menanggalkan plak, atau sama ada penggunaannya dapat mengurangkan keradangan gusi (gingivitis) dan mencegah atau melambatkan perkembangan penyakit periodontium.

Ciri kajian

Penulis-penulis daripada Kumpulan Kesihatan Oral Cochrane menjalankan ulasan kajian sedia ada dan bukti adalah terkini sehingga 23 Januari 2014. Ia melibatkan 56 kajian yang terbit dari 1964 hingga 2011, melibatkan 5068 peserta yang menerima secara rawak berus gigi letrik atau berus gigi manual. Kebanyakan kajian melibatkan orang dewasa dan lebih 50% kajian menggunakan berus gigi letrik yang mempunyai pergerakan berpusing (di mana kepala berus gigi berputar dalam satu arah dan ke arah satu lagi).

Kepututsan utama

Bukti yang terhasil menunjukkan faedah mengguna berus gigi letrik berbanding berus gigi manual.Terdapat 11% pengurangan plak pada satu hingga tiga bulan penggunaan dan 21% pengurangan plak bila dinilai selepas tiga bulan penggunaan. Bagi gingivitis, terdapat 6% pengurangan pada satu hingga tiga bulan penggunaan dan 11% apabila dinilai selepas tiga bulan penggunaan. Namun faedah jangka panjang untuk kesihatan pergigian adalah tidak jelas.

Sebilangan kajian melaporkan kesan sampingan: sebarang kesan sampingan yang dilaporkan adalah bersifat setempat dan sementara sahaja.

Kualiti bukti

Bukti mengenai plak dan gingivitis adalah berkualiti sederhana.

Catatan terjemahan

Diterjemah oleh Noorliza Mastura Ismail, Kolej Perubatan Melaka-Manipal. Disunting oleh Teguh Haryo Sasongko, Universiti Sains Malaysia. Untuk sebarang pertanyaan berkaitan terjemahan ini sila berhubung dengan noorliza.mastura@manipal.edu.my

Summary of findings(Explanation)

Summary of findings for the main comparison. 
  1. 1. Based on median of control means for all trials presenting data using Quigley Hein index at 1 to 3 months

    2. Based on median of control means for all trials presenting data using Löe and Silness index at 1 to 3 months

    3. Downgraded due to statistically significant heterogeneity (I2 = 83% for plaque; I2 = 82% for gingivitis)

    4. No downgrading was undertaken for risk of bias although 46/56 included trials were assessed as being at unclear risk of bias. Given that many of the studies were conducted over 10 years ago, it was felt much of the uncertainty may be due to poor reporting

Powered toothbrushes compared with manual toothbrushes for oral health

Patient or population: Individuals of any age with no reported disability that might affect toothbrushing

Intervention: Powered toothbrushes with any mode of action

Comparison: Manual toothbrushes

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments
Assumed riskCorresponding risk
Manual toothbrushPowered toothbrush

Plaque scores at 1 to 3 months

Scale from: 0 to 5

The mean plaque score in the control group was 2.16 points1The mean plaque score in the intervention groups was
0.23 lower (0.32 lower to 0.14 lower)
 2871 (40 studies)⊕⊕⊕⊝
moderate3,4

This effect represents an 11% reduction in plaque at 1 to 3 months

Long-term data (>3 months) also showed a statistically significant reduction in plaque for powered toothbrushes compared to manual toothbrushes

Gingival scores at 1 to 3 months

Scale from: 0 to 3

The mean gingivitis score in the control group was 1.1 points2The mean gingivitis score in the intervention groups was
0.07 lower (0.10 lower to 0.04 lower)
 3345
(44 studies)
⊕⊕⊕⊝
moderate3,4

This effect represents a 6% reduction in gingivitis at 1 to 3 months

Long-term data (>3 months) also showed a statistically significant reduction in gingivitis for powered toothbrushes compared to manual toothbrushes

Adverse eventsThere was no apparent relationship between the use of powered toothbrushes and soft tissue trauma. In part this finding was due to the very small number of adverse events reported in the trials
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

Background

Description of the condition

Periodontal diseases

Periodontal diseases are a diverse family of oral health conditions affecting the periodontium. As the most prevalent periodontal diseases, gingivitis and periodontitis are of major public health importance. Dental plaque is the primary cause of gingivitis (gum inflammation), which is recognised by redness of the gums at the junction with the teeth, together with slight swelling and bleeding from the gingival margin (Farina 2013). Globally, 80% to 90% of adolescents between 15 and 19 years of age have mild to moderate gingivitis, rising to 92% to 97% in adults between 35 and 44 (Petersen 2012).

Gingivitis can progress to involve the periodontal membrane (periodontitis). A pocket between the gingiva and the tooth forms, and with further destruction bone supporting the tooth is eroded. Eventually the tooth becomes mobile and can be lost. This is a slow process and is related to the amount of plaque and calculus present on the tooth surface, mediated by genetic factors, age, and lifestyle choices such as smoking (British Society of Periodontology 2012). Severe periodontitis is the sixth most prevalent condition, affecting 11% of the global population (Marcenes 2013) and tooth loss as a result is found in 5% to 20% of most adult populations worldwide (Petersen 2005).

Dental caries

Caries (decay) in permanent teeth is the most prevalent disease worldwide, with a global prevalence of 35% for all ages combined (Marcenes 2013). Whilst in high-income countries the prevalence of caries has decreased over the past decade, in lower- and middle-income countries (LMICs) the incidence is increasing due to population growth, an aging population, changing diets and inadequate exposure to fluorides (Marcenes 2013). In the United Kingdom (UK), 85% of adults have at least one filling (Steele 2011) and 31% have obvious untreated caries (White 2011). 

The presence of plaque (biofilm) on the tooth is necessary for the development of caries. Like periodontal disease, caries has a complex aetiology, being an interaction between lifestyle, particularly diet and fluoride use, together with host factors. Although the relationship between the presence of plaque and caries is not as clear as with gingivitis, there is clear evidence that the presence of plaque makes teeth more at risk of caries. Zenkner 2013 demonstrated that on erupting teeth with visible plaque accumulation were 14.5 times more likely to have caries than teeth without the presence of visible plaque.

Over twice as many adults who reported not brushing their teeth have caries compared to those who report brushing their teeth twice a day (White 2011). Almost all people in industrialised countries use fluoride toothpaste. When teeth are brushed with a fluoride toothpaste there is clear evidence that this is effective at preventing caries (White 2011) and that this is overall more important than brushing per se (Chesters 1992).

Description of the intervention

Powered versus manual toothbrushing for oral health

Good oral hygiene (the removal of plaque or biofilm from the tooth and gums) by effective toothbrushing has a key role in oral health. In general, populations of high-income countries have adopted regular toothbrushing (Albertsson 2010). There is, however, substantial within-country variation correlating strongly with educational level (Chen 1997). Toothbrushing is much less frequent in LMICs but is again associated with social status indicators (McKittrick 2014).

Effective toothbrushing depends on a number of factors including motivation, knowledge and manual dexterity. Powered brushes simulate the manual motion of toothbrushes with lateral and rotary movements of the brush head. Brushes which operate at a higher frequency of vibration have also been introduced (Johnson 1994; Terezhalmy 1995b). Powered toothbrushes were first introduced commercially in the early 1960s (Chilton 1962a; Cross 1962; Elliot 1963; Hoover 1962) and have become established as an alternative to manual methods of toothbrushing. In the UK a quarter of adults report using a powered toothbrush (Chadwick 2011) and use by children may be even higher (White 2004). 

How the intervention might work

Dental plaque is the primary cause of gingivitis and is implicated in the progression of periodontitis. Therefore more effective removal of plaque by a powered toothbrush compared to a manual brush will reduce the inflammation of the gums (gingivitis), a benefit in itself, and in the long term may prevent or slow the progression of periodontitis and therefore maintain a functioning dentition for longer (Aspiras 2013). 

There is a potential to reduce caries incidence by the effective removal of plaque (Zenkner 2013) but previous reviews on the effectiveness of powered toothbrushes have not identified any studies reporting this outcome (Deacon 2010; Robinson 2005).

Why it is important to do this review

Powered toothbrushes are popular and expensive compared to manual toothbrushes. However, the question remains, which is better, powered or manual? This is an update of the Cochrane review first published in 2003 and previously updated in 2005 comparing powered and manual toothbrushes (Heanue 2003; Robinson 2005). There is also a related review comparing the effectiveness of different designs of powered toothbrushes (Deacon 2010). However, the previous review comparing powered and manual toothbrushes was published in 2005, and there is a requirement to update that review to identify new evidence, and to include any evaluations of new designs of powered toothbrush introduced to the market.

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.

Methods

Criteria for considering studies for this review

Types of studies

The review is confined to randomised controlled trials comparing manual and powered toothbrushes. It excludes trials only comparing different kinds of powered brushes or those comparing different kinds of manual brushes.

In the current update an agreement was made that cross-over trials were eligible for inclusion if the wash-out period length was more than two weeks. This was particularly important to diminish any carry-over effects of the different toothbrushes on clinical gingivitis. Split-mouth trials were excluded, as these were not considered representative of 'everyday use'.

Studies were included irrespective of publication status or language.

Types of participants

We included individuals of any age with no reported disability that might affect toothbrushing. We also included individuals wearing orthodontic appliances.

Types of interventions

The toothbrushes included in the review were all forms of manual brushes and all forms of powered brushes. Trials instituting combined interventions, e.g. brushing combined with the use of mouthrinse or irrigation, were excluded. However, trials where participants were permitted to continue with their usual adjuncts to oral hygiene, such as flossing, were included.

Trials were excluded where the brushing intervention was carried out or was supervised by a professional less than 28 days before a follow-up assessment.

Trials of 28 days and over were eligible and a subgroup analysis was carried out on the duration of trials for the different outcome measures.

Powered toothbrushes were divided into seven groups according to their mode of action.

  1. Side to side action, indicates a brush head action that moves laterally from side to side.

  2. Counter oscillation, indicates a brush action in which adjacent tufts of bristles (usually six to 10 in number) rotate in one direction and then the other, independently. Each tuft rotating in the opposite direction to that adjacent to it.

  3. Rotation oscillation, indicates a brush action in which the brush head rotates in one direction and then the other.

  4. Circular, indicates a brush action in which the brush head rotates in one direction.

  5. Ultrasonic, indicates a brush action where the bristles vibrate at ultrasonic frequencies (> 20 kHz).

  6. Ionic, indicates a brush that aims to impart an electrical charge to the tooth surface with the intent of disrupting the attachment of dental plaque.

  7. Unknown, indicates a brush action that the review authors have been unable to establish based on the trial report or confirm with the manufacturers.

An additional group was added in a parallel review of the effectiveness of different powered brushes (Deacon 2010). This 'multidimensional group' included brushes with two of the above action types. Due to the limited number of trials conducted using this brush type, they were considered as part of the rotation oscillation group in this update.

It was agreed from the earlier reviews that analysis of filament arrangement, orientation, size, shape and flexibility, brush head size and shape along with presence or absence and characteristics of a timer would prove difficult to define across time and brush types.

Types of outcome measures

Primary outcomes

The primary outcome measures employed were quantified levels of plaque or gingivitis or both. Where possible, values recorded on arrival at the assessment were used. If necessary, measures of gingivitis taken after participants had been instructed or permitted to brush their teeth at the assessment visit were used as it was assumed that toothbrushing would not affect gingivitis within such a short period. However, measures of plaque taken after participants had been instructed or permitted to brush their teeth at the assessment visit were not used. It was assumed that plaque scores achieved during toothbrushing under these circumstances would not reflect scores achieved in normal home use.

Secondary outcomes

Secondary outcome measures sought were levels of calculus and staining; dependability and cost of the brush used, including mechanical deterioration; and adverse effects such as hard or soft tissue injury and damage to orthodontic appliances and prostheses.

Future updates of this review will include caries as an outcome.

Search methods for identification of studies

For the identification of studies included or considered for this review, we developed a detailed search strategy for each database, based on the strategy developed for MEDLINE (OVID) but revised accordingly. The search strategy used a combination of controlled vocabulary and free text terms and was linked with the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials (RCTs) in MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 (updated March 2011) (Higgins 2011). Details of the MEDLINE search are provided in Appendix 3. The searches of EMBASE and CINAHL were linked to the Cochrane Oral Health Group filters for identifying RCTs.

Electronic searches

We searched the following electronic databases:

  • the Cochrane Oral Health Group's Trials Register (to 23 January 2014) (Appendix 1);

  • the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1) (Appendix 2);

  • MEDLINE via OVID (1946 to 23 January 2014) (Appendix 3);

  • EMBASE via OVID (1980 to 23 January 2014) (Appendix 4);

  • CINAHL via EBSCO (1980 to 23 January 2014) (Appendix 5).

No restrictions were placed on the language or date of publication when searching the electronic databases.

Searching other resources

We searched the following databases for ongoing trials, see Appendix 6 for details of the search strategy:

Only handsearching done as part of the Cochrane Worldwide Handsearching Programme and uploaded to CENTRAL was included (see the Cochrane Masterlist for details of journal issues searched to date).

All references cited in the included trials were checked for additional studies. Identified manufacturers were contacted and additional published or unpublished trial reports requested.

Data collection and analysis

Selection of studies

Two review authors independently reviewed the titles and abstracts identified in the search. If in the opinion of both authors an article clearly did not fulfil the defined inclusion criteria it was considered ineligible. We obtained full reports of all trials of possible relevance for assessment. On receipt of the full article, two review authors assessed each study independently using specifically designed data extraction forms. Disagreements were resolved by discussion with the review team.

Data extraction and management

For this update, piloting of data extraction was performed independently by two authors on eight pilot articles. However, all authors reported back on the design of the data extraction forms and their interpretation of the inclusion and exclusion criteria along with their understanding of the outcome measures and new risk of bias (ROB) assessment. On the basis of this feedback the data extraction forms were altered and the inclusion, exclusion, outcome measures and ROB assessment were redefined to avoid misinterpretation. All data extraction for the included studies was then undertaken independently and in duplicate.

The final data extraction protocol considered the following information.

  1. Bibliographic details of the study.

  2. Funding source for the trial. A trial was considered to have been funded by a brush manufacturer if it was reported that any material sponsorship from the manufacturer occurred, including the donation of brushes. It was considered unclear, if there was no statement on funding. A trial was only considered to be unsponsored by a manufacturer if it clearly stated so.

  3. Inclusion eligibility.

  4. Baseline characteristics of the participants in the study, including age, number of participants in the study and gender. Also, specific groups, such as dental students or orthodontic patients were noted, where mentioned.

  5. Intervention characteristics including type of brush and its mode of action, duration of use and delivery of instructions.

  6. Outcomes including plaque and gingivitis indices.

  7. Additional information on a priori calculation of sample size, duration of study, reliability and validity of outcomes measures and monitoring of compliance.

Trials were considered as 'short term' or 'long term'. 'Short-term' data included follow-up between 28 days and three months. 'Long-term' data included follow-up beyond three months. Within each category of long term and short term, where a trial reported multiple end points, only the latest data were extracted.

Data from trials that reported follow-up before and after three months were included in the short- and long-term meta-analyses. Likewise, data from trials that reported both plaque and gingivitis would be included in meta-analyses for both outcomes. These were the only circumstances when data from the same trial were considered more than once.

Many different indices of plaque and gingivitis were used across trials and some trials reported multiple indices. A frequencies table was prepared of the indices used and they were ranked based on common usage and simplicity. For plaque we extracted, where possible, data reported as the Turesky modification of the Quigley-Hein plaque index (Quigley 1962; Turesky 1970). For gingival inflammation we extracted where possible data reported as the gingival index of Löe and Silness (Löe 1963) or, if unavailable, bleeding on probing (Ainamo 1975). Data for Russell's periodontal index were excluded because this index fails to distinguish between gingivitis and periodontitis (Russell 1967).

Where available, data were extracted for whole as opposed to part-mouth scores. Where only part-mouth scores were reported in a study, they were extracted and a sensitivity analysis carried out to consider their impact on the results of the review. Part-mouth scoring was said to have occurred if plaque or gingivitis or both were not recorded around all erupted teeth, except third molars.

Completed data extraction forms were compared. Where there was disagreement between review authors with regard to any part of the extraction details it was resolved by discussion between the authors and a note made on the data collection forms. Any disagreement, unresolved between the two authors, was settled by majority vote of the entire panel of review authors. Authors were contacted for clarification where necessary.

Assessment of risk of bias in included studies

We conducted this assessment using the recommended approach for assessing risk of bias in included studies for Cochrane reviews (Higgins 2011). All included studies were assessed independently and in duplicate by two review authors as part of the data extraction process. The risk of bias tool evaluates six specific domains.

  • Sequence generation (selection bias).

  • Allocation concealment (selection bias).

  • Blinding of outcome assessment (detection bias).

  • Incomplete outcome data (attrition bias).

  • Selective outcome reporting (reporting bias).

  • Other sources of bias; comparability of groups at baseline.

Risk of bias assessment.

  • A trial was considered to have adequately generated a random sequence of allocation, if it fully reported the type of allocation generation and it satisfied the CONSORT guidelines as true randomisation (http://www.consort-statement.org/).

  • A trial was considered to have adequate blinding, if the report indicated that the method of outcome assessment did not allow the recording clinician to know to which group the participants had been allocated, with no other contradicting statement.

  • Attrition was considered to have been adequately reported if there was a clear indication of how many withdrawals occurred in each group during the trial and an attempt made to give reasons why the withdrawals occurred.

The first part of the entry involved authors' describing what was reported in the study. The second part involved the authors' judgements of the adequacy of the study, that is, whether they are at low, high or unclear risk of bias. Numerical data extracted from the included trials were checked by a third author for accuracy and entered into Review Manager (RevMan) software (RevMan 2012).

Two risk of bias figures were generated to illustrate the findings of the assessment. A 'Risk of bias graph' illustrated the proportion of studies across the domain with each of the judgements ('low risk', 'high risk', 'unclear risk'). A 'Risk of bias summary' summarised all of the judgements for a study entry. We assumed that the risk of bias of outcomes was equally important both within and across studies. They were assessed as follows.

Low risk of biasInterpretationWithin a studyAcross studies
Low risk of biasPlausible bias unlikely to seriously alter the resultsLow risk of bias for all key domainsMost information is from studies at low risk of bias
Unclear risk of biasPlausible bias that raises some doubt about the resultsUnclear risk of bias for one or more key domainsMost information is from studies at low or unclear risk of bias
High risk of biasPlausible bias that seriously weakens confidence in the resultsHigh risk of bias for one or more key domainsThe proportion of information from studies at high risk of bias is sufficient to affect the interpretation of results

Measures of treatment effect

The estimate of effect used was the mean difference (MD) and corresponding 95% confidence intervals (CI). However, different indices for plaque measure the same concept on different scales, with high correlation between the different indices. The same is true for gingivitis. As it is not possible to combine the results from different indices, the effects were expressed as standardised values, which have no units, before combining. The standardised mean difference (SMD) was therefore calculated along with the appropriate 95% CI and was used as the effect measure for each meta-analysis where results were available for more than one index (Deeks 2001). Where only one index was presented in a comparison, the treatment effect was measured as the MD with 95% CI.

Unit of analysis issues

No units of analysis issues were anticipated other than cross-over studies which were included using the generic inverse variance (GIV) approach (Elbourne 2002; Higgins 2011).

Dealing with missing data

Trial authors were contacted to retrieve missing data where necessary. Data remain excluded until further clarification becomes available. Standard deviations were imputed as in section 7.7.3 of the Cochrane Handbook for Systematic Reviews of interventions (Higgins 2011).

Assessment of heterogeneity

We assessed heterogeneity by inspection of a graphical display of the estimated treatment effects from the trials along with their 95% CI and by Cochran's test for heterogeneity undertaken before each meta-analysis as described in the Cochrane Handbook for Systematic Reviews of interventions (Higgins 2011). The heterogeneity was quantified using the I2 statistic, where a guide for interpretation in the Cochrane Handbook for Systematic Reviews of interventions is (Higgins 2011):

  • 0% to 40%: might not be important;

  • 30% to 60%: may represent moderate heterogeneity;

  • 50% to 90%: may represent substantial heterogeneity;

  • 75% to 100%: considerable heterogeneity.

Assessment of reporting biases

A funnel plot (plots of effect estimates versus the inverse of their standard errors) was drawn. Asymmetry of the funnel plot may indicate publication bias and other biases related to sample size, though it may also represent a true relationship between trial size and effect size. A formal investigation of the degree of asymmetry was performed using the method proposed by Egger et al (Egger 1997). This was carried out using Stata version 12.0 (Stata Corporation, USA) using the program Metabias.

Data synthesis

Statistical values such as SMD have no inherent clinical meaning. Therefore we back-translated key effect scores using the clinical indices from a study where the difference was similar to the SMD. Such examples are given in the Discussion. Random-effects models were performed where four or more studies were to be combined, otherwise fixed-effect models were used.

Data from cross-over trials were included with that of similar parallel group trials, using the techniques described by Elbourne and colleagues (Elbourne 2002). This was done using the generic inverse variance method within RevMan (Higgins 2011).

Subgroup analysis and investigation of heterogeneity

Subgroup analyses were undertaken for assessments based on full mouth recording versus those based on a partial recording and to examine the effects of concealed allocation, randomisation generation and blinded outcome assessment on the overall estimates of effect for important outcomes.

Additional subgroup analyses were undertaken to explore heterogeneity. Evidence of variability in any subgroup was further explored by examining funnel plots.

Sensitivity analysis

Sensitivity analyses were conducted to test whether the assumptions involved in the design of this review affected the findings. These analyses were undertaken by repeating the meta-analyses in the following cases: where a full mouth index had been used, where adequate concealment of randomisation occurred, where there was adequate generation of randomisation sequence, where there was blinding of the outcome assessor, if the trial was funded by a manufacturer, with adequate information about attrition and for trials that were not restricted to participants only wearing fixed orthodontic appliances.

Presentation of main results

A GRADE approach was used to interpret findings. A 'Summary of findings' table was developed for the primary outcomes of this review using GRADE Profiler software (version 3.6). These tables provide information concerning the overall quality of the evidence from the trials, the magnitude of effect of the interventions examined, and the sum of available data on the primary outcomes and secondary outcomes. The outcomes selected for inclusion in these tables were plaque and gingivitis at two time points.

Results

Description of studies

Results of the search

See Figure 1.

Figure 1.

Flow chart of study selection in this update.

This review was originally published in 2003, updated in 2005 and again for this version. Since its first publication to January 2014 a total of 1195 articles have been identified through the search strategy. After removing duplicates, this number falls to 432; titles and abstracts of these 432 articles were screened for eligibility. A total of 200 full-text articles were retrieved as potentially relevant trials. Of these, 134 were excluded (Characteristics of excluded studies table) leaving 56 trials, in 66 publications.

In the original review 29 trials, all providing data for meta-analysis, were included. In the 2005 update, an additional 10 trials were identified as meeting the inclusion criteria (Galgut 1996; Garcia-Godoy 2001; Hickman 2002; Pucher 1999; Sharma 2000; Soparkar 2000; Sowinski 2000; Toto 1966; Van Swol 1996; Zimmer 2002). Data for three trials identified in the original search was received from the authors allowing their inclusion (Haffajee 2001a; Lapiere unpublished; Singh unpublished). Thus 42 trials were included in the 2005 publication.

In the current update, an additional 15 trials were identified as being eligible (Biavati Silvestrini 2010; Biesbrock 2007; Costa 2007; Dorfer 2009; Goyal 2007; Gugerli 2007; Kallar 2011; McCracken 2004; McCracken 2009; Moreira 2007; Moritis 2008; Rosema 2008; Sharma 2010; Silverman 2004; Zimmer 2005). Fourteen were parallel group designs and there was one cross-over trial (Moreira 2007). One trial included in the original review was excluded as it was not truly a randomised controlled trial (McAllan 1976), leaving a total of 56 trials included in this 2014 update. Of these 56 trials, five did not present data in a way that allowed for meta-analysis (Costa 2007; Galgut 1996; Gugerli 2007; Moreira 2007; Zimmer 2005). The meta-analyses are based on 51 trials with a parallel group design.

Included studies

Of the 56 included trials, 36 were conducted in North America (Baab 1989; Barnes 1993; Biesbrock 2007; Costa 2007; Cronin 1998; Dentino 2002; Emling 1991; Forgas-B 1998; Garcia-Godoy 2001; Glass 1965; Goyal 2007; Haffajee 2001a; Ho 1997; Johnson 1994; Khocht 1992; Lobene 1964a; Moreira 2007; O'Beirne 1996; Pucher 1999; Sharma 2000; Sharma 2010; Silverman 2004; Singh unpublished; Soparkar 1964; Soparkar 2000; Sowinski 2000; Terezhalmy 1995a; Toto 1966; Tritten 1996; Van Swol 1996; Walsh 1989; Warren 2001; Wilson 1993; Yankell 1996; Yankell 1997; Yukna 1993b); 18 in Europe (Ainamo 1997; Biavati Silvestrini 2010; Clerehugh 1998; Dorfer 2009; Galgut 1996; Gugerli 2007; Heasman 1999; Hickman 2002; Lapiere unpublished; Lazarescu 2003; McCracken 2004; McCracken 2009; Moritis 2008; Rosema 2008; Stoltze 1994; van der Weijden 1994; Zimmer 2002; Zimmer 2005), one each in Israel (Stabholz 1996) and in India (Kallar 2011).

Three trials remain unpublished (Lapiere unpublished; Lazarescu 2003; Singh unpublished). The remainder were published between 1964 and October 2011; four in the 1960s; one in the 1970s; two in the 1980s; 23 in the 1990s and 19 in the 20th century. At least 37 were funded in some part by the manufacturer of one of the powered toothbrushes, one was funded by government scholarship and the remainder were unclear about sponsorship.

The combined total number of participants included in the trials was 5068. The number of patients reported lost to follow-up was 334 (6.6%).

Characteristics of participants

The characteristics of participants in each study are noted in the Characteristics of included studies table and in Additional Table 1. Out of the 56 included trials the four most frequently stated inclusion criteria were adults (77% of trials), no relevant medical history (55%), a stated minimum number of teeth (55%) and a criterion related to gingival or periodontal health or plaque at baseline (50%). Exclusion criteria used in the included trials were noted and are summarised in Additional Table 2. Only seven trials included orthodontic patients (Biavati Silvestrini 2010; Clerehugh 1998; Costa 2007; Hickman 2002; Ho 1997; Pucher 1999; Singh unpublished).

Table 1. Summary of inclusion criteria categories within included studies
Inclusion criteriaNumber (n = 56)
Adults43
Minimum number of teeth31
Minimum periodontal baseline measures28
Participants recruited from dental clinics9
Concurrent fixed orthodontic treatment8
Some participants aged less than 16 years11
Volunteer university students3
Dental students2
School children3
Table 2. Summary of exclusion criteria categories within included studies
  1. 1 Not all trials explicitly stated exclusion criteria

Exclusion criteria1Number (n = 56)
Exclusion criteria related to medical history31
Pregnancy or lactation5
Previous use of powered toothbrushes6
Patients undergoing orthodontic treatment9
Previous periodontal treatment3
Dental students2
Cervical restorations1
Smoking3
Maximum periodontal measure8
Wearing partial denture2
Characteristics of interventions

The powered toothbrushes, included:

Braun, Interplak, Braun Plaque Remover with OD5 head, Braun Oral B Pro Care series, Oral B CrossAction, Braun Oral B Pro Care 8500, Braun Oral B D25, Braun Oral B 3D, Braun Oral B D9, PlaK Trac, Ultrasonex, GEC, Braun Oral B D7, Philips Jordan HP 735, Philips HP 550, Sonicare Ultrasonic, Philips Sonicare, Philips Sensiflex 2000, Philips Sonicare Elite, Epident, Braun Oral B D5, Philips 550, Touchtronic Teledyne Aqua Tec, Ronson, Dominion, Pulse Plaque Remover, Broxodent, Plaq and White, LPA/Broxo, Braun D17, Rowenta Dentiphant, Rowenta, Plaque Dentacontrol Plus, Sangi Co Electronic, Braun Oral B D10, Braun Oral B D15 Plaque Remover, Braun Plaque Remover 3D with orthodontic head, Oral B Mickey Mouse, Hukuba Ionic, Colgate Actibrush, HyG Ionic, unspecified ionic, Ultra Sonex Ultima, Ultreo, Sunbeam cordless. These are summarised in Additional Table 3.

Table 3. Summary of toothbrush modes of action, number of trials and participants
  1. Four trials evaluated two powered toothbrushes

Mode of actionTrial IDNumber of trialsNumber in trials
Side to sideGlass 1965, Ho 1997, Johnson 1994, Lobene 1964, McCracken 2009, Moritis 2008, O'Beirne 1996, Tritten 1996, Walsh 1989, Yankell 199710988
Counter oscillationBaab 1989, Khocht 1992, Stabholz 1996, Wilson 1993, Yukna 19935267
Rotation oscillationAinamo 1997, Barnes 1993, Biavati Silvestrini 2010, Biesbrock 2007, Clerehugh 1998, Costa 2007, Cronin 1998, Dentino 2002, Dorfer 2009, Garcia-Godoy 2001, Gugerli 2007, Haffajee 2001a, Heasman 1999, Hickman 2002, Lapiere unpublished, Lazarescu unpublished, McCracken 2004, Rosema 2008, Sharma 2000, Silverman 2004, Soparkar 2000, Sowinski 2000, Stoltze 1994, van der Weijden 1994, Warren 2001, Yankell 1997, Zimmer 2005272159
CircularKhocht 1992, Yankell 19962162
UltrasonicCosta 2007, Forgas-B 1998, Goyal 2007, Sharma 2010, Terezhalmy 1995, Zimmer 2002, Zimmer 20057506
UnknownEmling 1991, Kallar 2011, Singh unpublished, Soparkar 1964, Toto 196651130
IonicGalgut 1996, Moreira 2007, Pucher 1999, van Swol 19964221
Powered toothbrush, mode of action

The powered toothbrushes were subdivided into the seven groups according to their mode of action.

Side to side action

Philips Sonicare, Philips Sonicare Elite and Sonicare brushes (Sonicare c/o Philips Oral Healthcare, 35301 SE Center Street, Snoqualmie, WA 98065; http://www.sonicare.com/); Philips 550 (Philips Jordan, PO Box 324, 5500 AH Veldhoven, The Netherlands; http://www.philips-jordan.com/) and Philips Sensiflex 2000 (http://www.philips.co.uk/c/electric-toothbrushes/sensiflex-hx1610_05/prd/).

Counter oscillation

Interplak brush (Interplak Conair Corporation, 1 Cummings Point Road, Stamford, CT 06904; http://www.conair.com/products/).

Rotation oscillation

Oral B CrossAction, Braun Oral B 3D, D17, Plaque Remover with OD5 head, Oral B D9, Oral B D7, Oral B D5, Oral B D10, Oral B D25, Oral B Pro Care 8500, Oral B Mickey Mouse, Braun Plaque Remover 3D with orthodontic head, Braun Oral B D15 Plaque Remover (Braun Oral B Consumer Services, 1 Gillette Park, South Boston, MA; http://www.oralb.com/); Philips Jordan HP 735, Philips HP 550 (Philips Jordan PO Box 324, 5500 AH Veldhoven, The Netherlands; http://www.philips-jordan.com/); Colgate Actibrush (Consumer Affairs, Colgate-Palmolive (UK) Limited, Guildford Business Park, Middleton Road, Guildford, Surrey GU2 8JZ UK; http://www.colgate.co.uk/contact/index.shtml).

Circular

Rowenta Dentiphant, Rowenta, Plaque Dentacontrol Plus (Rowenta Werke GmbH, Franz Alban, Stützer, Germany; http://www.products.rowenta.de/row/index.html); Epident (EPI Products, Santa Monica, CA).

Ultrasonic

Ultrasonex brush, Ultra Sonex Ultima (Salton-Maxim 1801 N Stadium Boulevard, Columbia, MO 65202; http://www.salton-maxim.com/salton/ultrasonex/ultrasonex.asp) and Ultreo (http://www.ultreo.com/meet-ultreo), Oral B Pulsonic.

Ionic

Sangi Co Electronic (Tokyo), Hukuba Ionic and the HyG Ionic (Hukuba Dental Corporation, 914-1 Nazukari, Nagareyama, Chiba, 270-01 Japan).

Unknown

Some companies are no longer trading or complete details of the relevant toothbrushes are not easily found. The following toothbrushes fall into this latter category: PlaK Trac, GEC, Epident, Touchtronic, Ronson, Dominion, Broxodent, Plaq and White, LPA/Broxo, Sunbeam cordless.

The names and addresses of the manufacturers have changed over the years and those quoted above are correct at the time of the present review. Some of the trials were conducted when another company made the powered toothbrush.

Ten trials recruiting 988 participants compared manual brushing versus side to side powered toothbrushing. Five trials recruited 267 participants and compared manual brushing versus counter oscillating toothbrushing. Twenty-seven trials recruiting 2159 participants compared manual brushing versus rotation oscillation powered brushing. Two trials recruiting 162 participants compared manual brushing versus circular powered brushing and seven trials recruiting 506 participants compared manual brushing versus ultrasonic powered brushing. Four trials recruiting 221 participants compared manual brushing versus ionic brushing. Five trials recruiting 1130 participants compared manual brushing and a powered toothbrush with an unknown action. It should be noted that four trials evaluated two powered brushes (Costa 2007; Khocht 1992; Yankell 1997; Zimmer 2005).

Summary of trials by toothbrush action

See Additional Table 3 for list of trials by mode of action.

Characteristics of outcome measures

Forty trials (2871 participants at the end of the trials) provided data for analysis on plaque at one to three months and 14 trials (978 participants at the end of the trials) provided data at longer than three months. Forty-four trials (3345 participants at the end of the trials) provided data for analysis on gingivitis at one to three months and 16 trials (1645 participants at the end of the trials) provided data at longer than three months.

If it was not stated that a full or partial mouth index was used, we assumed it was full mouth. Fifty-four trials reported plaque data, and of these eight trials reported that a partial mouth assessment was used. Fifty-two trials reported gingivitis data and 10 of these reported using a partial mouth index.

The following plaque indices were reported.

The following gingivitis indices were reported.

Excluded studies

The primary reason for the exclusion of each study is given in the Characteristics of excluded studies table. Many trials were ineligible for more than one reason, however the primary reason for exclusion was study duration of less than 28 days. Other reasons included a high potential for compromised self toothbrushing efficacy; combined interventions that did not allow for assessment of the effect of powered toothbrushing; split-mouth design; or insufficient information to determine whether inclusion criteria were met (in these situations authors have been contacted and if further information is supplied to confirm criteria for inclusion are met, the studies will be included in subsequent updates).

Risk of bias in included studies

See Figure 2; Figure 3. Fifty-six studies were assessed for risk of bias, including five that were not meta-analysed (Costa 2007; Galgut 1996; Gugerli 2007; Moreira 2007; Zimmer 2005). Overall, only five were assessed as being at low risk of bias (Clerehugh 1998; Haffajee 2001a; McCracken 2009; Sharma 2010; Silverman 2004). Five trials were assessed as being at high risk of bias (Glass 1965; Kallar 2011; Lazarescu 2003; Walsh 1989; Wilson 1993).

Figure 2.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

The generation of randomisation sequence was at low risk of bias for 18 trials (32.1%), unclear risk for 36 (64.3%) and at high risk of bias for two trials (3.6%) (Lazarescu 2003; Walsh 1989). The concealment of allocation was at low risk of bias in 13 trials (23.2%) and unclear risk of bias in all other trials.

Blinding

The outcome assessment was at low risk of bias in 47 trials (83.9%). The adequacy of blinding was unclear in nine trials (16.1%).

Incomplete outcome data

The reported drop-out rate ranged from 1% to 34%. Forty-one trials were at low risk of bias with regard to attrition bias, either due to no drop-outs, or drop-outs unlikely to influence findings. Thirteen trials were at unclear risk of bias due to insufficient data for assessment; two studies with high drop-out rates that did not present reasons for the losses were assessed as at high risk of bias (Glass 1965; Wilson 1993).

Selective reporting

All of the trials apart from one reported important outcomes and were assessed as at low risk of bias. Kallar 2011 failed to report gingivitis and was assessed as at high risk of bias for this domain.

Other potential sources of bias

Two trials were at unclear risk of bias due to other potential sources (Kallar 2011; Yukna 1993b) due to lack of information on the methods or insufficient detail regarding baseline comparison. All other trials were assessed as at low risk of bias for this domain.

Effects of interventions

See: Summary of findings for the main comparison

As mentioned in the methods section, the differences in plaque and gingivitis reduction between the powered and manual brushes were expressed as standardised mean differences (SMDs) unless all the studies used the same index in which case mean difference (MD) was used. The results are presented for both short-term and long-term studies.

All powered toothbrushes versus manual toothbrushes (Comparison 1)

Analysis 1.1; Analysis 1.2; Analysis 1.3; Analysis 1.4.

This primary analysis compared all powered brush types with manual.

Plaque

The meta-analyses for both short-term (40 trials n = 2871) and long-term (14 trials n = 978) plaque indices indicated that there was a reduction in plaque when the powered toothbrushes were used, short term (one to three months) SMD -0.50 (95% confidence interval (CI) -0.70 to -0.31) and long term (>3 months) SMD -0.47 (95% CI -0.82 to -0.11). Both meta-analyses showed high levels of heterogeneity (I2 = 83% and 86% respectively). These were not explained by the different powered toothbrush type subgroups, and there was considerable heterogeneity within these.

Gingivitis

The meta-analyses for both short-term (44 trials n = 3345) and long-term (16 trials n = 1645) gingival indices indicated that there was a reduction in gingivitis when the powered toothbrushes were used, short term (1-3 months) SMD -0.43 (95% CI -0.60 to -0.25) and long term (>3 months) SMD -0.21 (95% CI -0.31 to -0.12). Both meta-analyses showed high levels of heterogeneity (I2 = 82% and 51% respectively). These were not explained by the different powered toothbrush type subgroups, and there was considerable heterogeneity within these.

Side to side powered toothbrushes versus manual toothbrushes (Comparison 2)

Analysis 2.1; Analysis 2.2; Analysis 2.3; Analysis 2.4.

Ten studies (n = 988) compared side to side toothbrushes with manual, one of which was at low risk (McCracken 2009) and two at high risk of bias (Glass 1965; Walsh 1989), the remainder being unclear.

No significant differences were found between side to side action and manual brushes in the reduction of plaque or gingivitis in the long or short term.

Counter oscillation powered toothbrushes versus manual (Comparison 3)

Analysis 3.1; Analysis 3.2; Analysis 3.3; Analysis 3.4.

All five studies (n = 267) that compared counter oscillation powered toothbrushes with manual toothbrushes were at unclear (Baab 1989; Khocht 1992; Stabholz 1996; Yukna 1993b) or high risk of bias (Wilson 1993). There was no evidence that counter oscillation powered toothbrushes were more effective than manual brushes for the removal of plaque or reduction of gingivitis with the exception of being associated with less plaque in the long term, where the MD was -0.27 (95% CI -0.48 to -0.07; two trials, n = 69; I2=0) (Analysis 3.3).

Rotation oscillation powered toothbrushes versus manual (Comparison 4)

Analysis 4.1; Analysis 4.2; Analysis 4.3; Analysis 4.4.

Twenty-seven trials (n = 2159) compared rotation oscillation powered with manual toothbrushes. Only three of these were at low risk of bias (Clerehugh 1998; Haffajee 2001a; Silverman 2004) and one at high risk of bias (Lazarescu 2003), the remainder being unclear. This comparison contained the greatest number of trials, with 20 (n = 1404) and 21 (n = 1479) trials included in the meta-analyses for plaque and gingivitis respectively in the short term, and seven (n = 527) and eight (n = 684) trials included in the meta-analyses for plaque and gingivitis in the long term. Brushes with a rotation oscillation action removed more plaque and reduced gingivitis more effectively than manual brushes in the short term. For plaque at one to three months the SMD was -0.53 (95% CI -0.74 to -0.31; I2 = 72%) (Analysis 4.1) and for gingivitis the SMD was -0.49 (95% CI -0.73 to -0.26; I2 = 78%) (Analysis 4.2). Rotation oscillation brushes also reduced plaque and gingivitis in the long term. The SMD for plaque over 3 months was -0.66 (95% CI -1.28 to -0.03; I2 = 91%) (Analysis 4.3) and for gingivitis was -0.35 (95% CI -0.50 to -0.20; I2 = 53%) (Analysis 4.4). There was heterogeneity between the trials in the meta-analyses for both short-term and long-term follow-up, which is reported later in this section.

Three studies examined both outcomes but did not include sufficient information for meta-analysis (Costa 2007; Gugerli 2007; Zimmer 2005). Two suggested treatment benefits from using rotation oscillation toothbrushes (Analysis 4.5). All three were at unclear risk of bias.

Circular powered toothbrushes versus manual (Comparison 5)

Analysis 5.1; Analysis 5.2.

Two trials (n = 162) were included in this comparison, both were at unclear risk (Khocht 1992; Yankell 1996). Both trials were included in the analyses for plaque and gingivitis in the short term; there were no long-term data. There was no evidence that brushes with a circular action removed plaque or reduced gingivitis more effectively than manual brushes in either time period.

Ionic toothbrushes versus manual (Comparison 6)

Analysis 6.1; Analysis 6.2; Analysis 6.3; Analysis 6.4.

Four trials (n = 221) compared an ionic toothbrush with a manual brush. All four trials were at unclear risk of bias (Galgut 1996; Moreira 2007; Pucher 1999; Van Swol 1996). One trial (Moreira 2007) did not present data in a form suitable for meta-analysis (Analysis 6.5).

Three trials provided data for meta-analysis (Galgut 1996; Pucher 1999; Van Swol 1996). The short-term analyses (one to three months) indicated an effect on plaque in favour of the ionic brush (SMD -0.57 (95% CI -0.87 to -0.27)) but not gingivitis (MD -0.01 (95% CI -0.04 to 0.02)).

The single long-term trial showed a difference in favour of the ionic toothbrush on both plaque (MD -0.50 (95% CI -0.74 to -0.26)) and gingivitis (MD -0.36 (95% CI -0.59 to -0.13)).

Ultrasonic toothbrushes versus manual (Comparison 7)

Analysis 7.1; Analysis 7.2; Analysis 7.3; Analysis 7.4.

Seven trials (n = 506) compared ultrasonic toothbrushes with manual. One of the seven trials in this comparison was at low risk of bias (Sharma 2010) and all others were at unclear risk of bias. There were four trials for the meta-analysis for the short-term assessment of plaque and five for gingivitis; two trials did not provide data for meta-analysis (Analysis 7.5). Ultrasonic powered toothbrushes reduced plaque and gingivitis in the short term, with SMDs of -1.33 (95% CI -1.59 to -1.07; I2 = 93%) (Analysis 7.1) and -0.99 (95% CI -1.21 to -0.76; I2 = 84%) (Analysis 7.2) respectively. Only one trial presented long-term data and showed no statistically significant difference between brushes for either plaque or gingivitis (Terezhalmy 1995a) (Analysis 7.3; Analysis 7.4).

Unknown versus manual (Comparison 8)

Analysis 8.1; Analysis 8.2; Analysis 8.3.

Five studies (n = 1130) compared powered brushes of unknown action against manual brushes. One was assessed as being at high risk of bias (Kallar 2011) and four were at unclear risk. The data are presented in forest plots however, due to the lack of clarity about the toothbrushes being compared it is difficult to draw any conclusions.

Investigation of heterogeneity

Heterogenity was present for both plaque at one to three months and plaque at >3 months and gingivitis at >3 months for the rotation oscillation brushes compared with manual. We were unable to put forward covariates other than those considered in the sensitivity analyses below to explain this.

Sensitivity analyses

Sensitivity analyses were limited to the data on all types of powered toothbrushes (Comparison 1: Analysis 1.1; Analysis 1.2; Analysis 1.3; Analysis 1.4) as this was the primary analysis for this review.

These were conducted for trials with (1) full mouth indices only, (2) low risk of bias trials, (3) manufacturer funded (reported) and (4) excluding orthodontic patients (Additional Table 4). The effect estimates were similar to those for all trials apart from those for the low risk of bias studies. There are only five low risk of bias trials in total and two to three included in the sensitivity analyses. Due to the lack of evidence none of these were statistically significant although the effect estimates for plaque and gingivitis at one to three months were higher than those for all trials.

Table 4. Sensitivity analyses of all trials for all indices
  1. SMD = standardised mean difference

IndexGroup selectedNumber of trialsSMDEffect P valueHet. P valueI2

Plaque

1-3 months

All trials40-0.50 (-0.70 to -0.31)<0.0001<0.000188
Full mouth34-0.58 (-0.80 to -0.36)<0.0001<0.000185
Low risk of bias3-0.83 (-2.02 to 0.36)0.17<0.000194
Manufacturer funded26-0.56 (-0.82 to -0.29)<0.0001<0.000188
Trials excluding ortho patients36-0.46 (-0.66 to -0.27)<0.0001<0.000183
 

Plaque

>3 months

All trials14-0.37 (-0.50 to -0.24)<0.0001<0.000186
Full mouth13-0.39 (-0.53 to -0.26)<0.0001<0.000187
Low risk of bias20.12 (-0.27 to 0.52)0.530.510
Manufacturer funded9-0.41 (-0.56 to -0.25)<0.0001<0.000191
Trials excluding ortho patients14 (all)-0.37 (-0.50 to -0.24)<0.0001<0.000186
 

Gingivitis

1-3 months

All trials44-0.43 (-0.60 to -0.25)<0.0001<0.000182
Full mouth35-0.47 (-0.68 to -0.25)<0.0001<0.000185
Low risk of bias3-0.96 (-1.95 to 0.03)0.06<0.000193
Manufacturer funded32-0.47 (-0.68 to -0.26)<0.0001<0.000184
Trials excluding ortho patients38-0.42 (-0.61 to -0.23)<0.0001<0.000183
 
Gingivitis >3 monthsAll trials16-0.21 (-0.31 to -0.12)<0.0001<0.000151
Full mouth14-0.25 (-0.37 to -0.13)<0.00010.00656
Low risk of bias2-0.12 (-0.52 to 0.27)0.540.520
Manufacturer funded10-0.21 (-0.35 to -0.07)0.0030.00368
Trials excluding ortho patients16 (all)-0.21 (-0.31 to -0.12)<0.0001<0.000151

Converting SMDs back to original indices

As the results of both gingivitis and plaque meta-analyses were calculated as SMDs, which are unit-less and difficult to interpret, we re-expressed them in Summary of findings table 1 by calculating SMDs back into the most commonly reported indices (Quigley Hein for plaque and Löe Silness for gingivitis). In order to back translate we calculated the mean difference by multiplying the median standard deviation of the control group (end of study mean) by the pooled SMD. The table below shows this for plaque and gingivitis in both the short and long term. The differences are also expressed as percentage reductions of the median control group mean.

Plaque index TimePooled SMDControl mean*Control standard deviation*Difference in mean scores (95% CI) Difference as % of control mean
Quigley Hein1-3 months-0.50 (-0.70 to -0.31)2.160.46-0.23 (-0.32 to -0.14)11%
Quigley Hein>3 months-0.47 (-0.82 to -0.11)1.050.46-0.22 (-0.38 to -0.05)21%
Gingivitis indexTimePooled SMDControl mean*Control standard deviation*Difference in mean scores (95% CI) Difference as % of control mean
Löe Silness1-3 months-0.43 (-0.60 to -0.25)1.10.16-0.07 (-0.10 to -0.04)6%
Löe Silness>3 months-0.21 (-0.31 to -0.12)0.740.4-0.08 (-0.12 to -0.05)11%

*median values for all trials presenting data using chosen indices (i.e. Quigley Hein for plaque; Löe Silness for gingivitis).

Publication bias

Publication bias was assessed for the studies included in the meta-analysis for all powered toothbrushes versus manual for the one to three month assessments. Both funnel plots appear asymmetrical in visual interpretation (Figure 4; Figure 5) with some evidence of publication bias. A formal test of small study effects (Egger test) was undertaken for the Quigley Hein (Turesky) index for plaque and the Löe Silness index for gingivitis. The slope was not significant for either index (P value = 0.203; 0.56) and the hypothesis of no small study effects was also not significant (P value = 0.748; 0.15). From the statistical tests there was no evidence of any publication bias.

Figure 4.

Funnel plot of Comparison 1: All powered toothbrushes versus manual toothbrushes, Outcome 1.1: Plaque scores at 1 to 3 months at all sites.

Figure 5.

Funnel plot of Comparison 1: All powered toothbrushes versus manual toothbrushes, Outcome 1.2: Gingival scores at 1 to 3 months at all sites.

Secondary outcomes

Cost

None of the included trials reported on the relative costs of manual compared with powered toothbrushes.

Reliability

One trial reported a mechanical failure of one of the 48 powered toothbrushes used (Clerehugh 1998) and one trial reported mechanical failure in four of 20 powered brushes (Yukna 1993b). No other mechanical failures were reported.

Calculus

Three trials (Dentino 2002; Glass 1965; van der Weijden 1994) reported on calculus, two reporting that there was no significant difference between the brush types (Glass 1965; van der Weijden 1994) and one reporting that, compared to the manual brush, the powered brush group showed a significant favourable difference in the accumulation of calculus at six months (P value < 0.01) (Dentino 2002).

Stain

Three trials reported that there was no difference in the degree of staining on the teeth between the brush types (Dentino 2002; Glass 1965; Walsh 1989).

Adverse events - Tissue trauma

There was no apparent relationship between the use of powered toothbrushes and soft tissue trauma. In part this finding was due to the very small number of adverse events reported in the trials.

Sixteen trials did not report on adverse events (Biavati Silvestrini 2010; Costa 2007; Galgut 1996; Goyal 2007; Haffajee 2001a; Ho 1997; Lazarescu 2003; Lobene 1964a; Moritis 2008; Rosema 2008; Sharma 2010; Silverman 2004; Soparkar 1964; Van Swol 1996; Zimmer 2002; Zimmer 2005 ). Of the 40 trials that did report on adverse events, 27 reported no trauma to soft or hard tissues or both (Ainamo 1997; Biesbrock 2007; Clerehugh 1998; Dentino 2002; Dorfer 2009; Emling 1991; Forgas-B 1998; Galgut 1996; Garcia-Godoy 2001; Glass 1965; Heasman 1999; Hickman 2002; McCracken 2009; Moreira 2007; Pucher 1999; Sharma 2000; Singh unpublished; Soparkar 2000; Sowinski 2000; Stabholz 1996; Stoltze 1994; Toto 1966; Walsh 1989; Warren 2001; Wilson 1993; Yankell 1996; Yankell 1997) and six reported no significant differences between powered and manual toothbrushes, or that tissue trauma was negligible (Baab 1989; Barnes 1993; Cronin 1998; Lapiere unpublished; O'Beirne 1996; Terezhalmy 1995a).

Therefore, of the 56 studies, there were seven trials that described differences in tissue trauma between participants using manual and powered toothbrushes. One trial reported five cases of gingival abrasion in the manual and one case of abrasion in the powered group (Tritten 1996), another reported 12 cases of gingival abrasion in the manual and five cases of gingival abrasion in the powered group (van der Weijden 1994). One trial reported seven soft tissue abnormalities in six participants in the manual group and 10 abnormalities in seven participants in the powered group (Johnson 1994). In the trial by Yukna et al (Yukna 1993b) four cases of abrasion were reported in the powered toothbrush group and one in the manual group. Khocht 1992 reported soft tissue changes in four participants using the manual toothbrush, six using the experimental powered toothbrush and one participant using a control powered toothbrush. In the trial by McCracken 2004, soft tissue lesion which included abrasion and ulcer were reported in eight of manual toothbrushes group and five in powered toothbrushes group. Gugerli 2007 reported three cases of abrasion in both manual and powered toothbrushes. These soft tissue changes were seen as transient irritations that were possibly/probably due to the product.

Discussion

We brush our teeth for many reasons: to feel fresh and confident; to have a nice smile; to avoid bad breath and to avoid disease. The selection of one's toothbrush is largely a matter of personal preference, affordability, availability and professional recommendation. Powered toothbrushes may have a particular appeal to some because they represent a 'high tech' solution to an everyday task. There is overwhelming evidence that toothbrushing reduces gingivitis (Lang 1973). It may prevent periodontitis and certainly prevents tooth decay if carried out in conjunction with fluoride toothpaste. These benefits occur whether the brush is manual or powered and the results of this review do not indicate that toothbrushing is only worthwhile with a powered toothbrush.

Summary of main results

The results of this review demonstrate that powered toothbrushes remove statistically significantly more plaque and gingivitis than manual brushes in both the short and long term. The results of the meta-analyses are presented as standardised mean differences (SMD), which do not relate to tangible differences in clinical indices. To help interpret the magnitude of the effect, the results of the 'all powered toothbrushes' meta-analysis have been back-translated to the most commonly reported plaque and gingivitis indices. An 11% reduction in plaque was shown at one to three months for the Quigley Hein (Turesky) index and a 21% reduction in plaque at longer than three months. The longer term result was based only on 14 trials, compared to 40 trials for the short-term analysis. With regard to gingivitis a 6% reduction was seen at one to three months for the Löe Silness index, based on 44 trials, and a greater reduction of 11% in the long term (16 trials).

When looking at individual modes of action of powered brushes there are inconsistencies with regard to reductions of plaque and gingivitis. Rotation oscillation brushes showed statistically significant reductions in both plaque and gingivitis at both time points. All other brushes, apart from side to side, showed some statistically significant findings but not consistently across both outcomes and time points. It is difficult to explain this inconsistency that a particular toothbrush design could affect plaque or gingivitis at one time but not at another and so the findings of these analyses may warrant further research, particularly given the small number of trials for some modes of action.

Overall completeness and applicability of evidence

The effectiveness of powered toothbrushes in removing plaque and reducing gingivitis can be related to destructive periodontal disease (periodontitis) only with some difficulty. Many factors are associated with the occurrence of periodontitis including plaque, tobacco use and individual medical factors. Periodontitis takes many years to develop whereas the trials have much shorter follow-up. There is little compelling evidence that plaque and gingivitis are reliable proxies for long-term destructive disease and it is difficult to estimate a threshold for clinically important reductions in either. We conclude that powered brushes reduce plaque accumulation and gingivitis but the clinical importance of these reductions cannot be assessed. More high quality long-term studies are required to investigate the effectiveness of rotation oscillation brushes in the treatment and prevention of periodontitis.

Some authorities have advocated the use of arbitrary thresholds to make superiority claims for a specific product. For example, Imrey has proposed that a product cannot be claimed to be superior unless it provides a 20% improvement in performance (which was not the case for any types of brush in this review, in terms of long-term plaque removal) (Imrey 1992; Imrey 1994). However, other authors have criticised the use of arbitrary thresholds and prefer a threshold for clinical significance to be decided in advance and selected on clinical grounds (D'Agostino 1992).

Few data were reported on the costs or reliability of the brushes or the side effects of their use. When reported, injuries to the gums were minor and transient.

Many factors may influence the effectiveness of toothbrushes including filament arrangement, orientation, size, shape and flexibility, brush head size and shape along with presence or absence and characteristics of a timer, that not all of them could be isolated and analysed. Whether the brush has a battery or rechargeable power source may also be important. These factors could be considered in subgroup analyses in the parallel review of different powered toothbrushes by Deacon and colleagues (Deacon 2010). More recently powered toothbrushes have been introduced with multidimensional actions (for example the filaments on some rotation oscillation brushes now also move in and out towards the tooth). Trials of such designs are yet to be identified.

The funnel plots for the trials of all powered toothbrushes were skewed for both plaque and gingivitis. This observation suggests but does not conclusively demonstrate publication bias. In the review intervention effects were measured by SMDs, which are naturally correlated with their standard error, which can produce spurious asymmetry in funnel plots. Other potential factors that may contribute to asymmetry include poor methodological quality of studies, true heterogeneity and the play of chance.

Publication bias might be expected in the reporting of toothbrush trials as manufacturers would like to have scientific support for the effectiveness of their products. Studies sponsored by pharmaceutical companies are more likely to favour the sponsor (Lexchin 2003). There was no evidence of this when publication bias was examined statistically, and no evidence of a difference in effect estimates when a sensitivity analysis was conducted for trials which did not mention commercial funding. It should be noted that the methods for detecting publication bias relate effect size to sample size, and in this review the trials tend to be of similar size. Therefore other methods may be required to examine publication bias in short-term, low cost studies.

Quality of the evidence

The current review focused purely on truly randomised trials. Five trials were assessed as at low risk of bias (8.9%), five at high risk of bias (8.9%) and the remaining 46 trials (82%) at unclear risk of bias. Only three trials were able to be used in the sensitivity analysis for trials at low risk of bias. These trials were unable to demonstrate statistically significant differences between powered and manual toothbrushes, although the effect estimates for plaque and gingivitis at one to three months were higher than those for all trials.

There was considerable unexplained heterogeneity in the meta-analyses for plaque and gingivitis for the primary analysis of powered toothbrushes versus manual brushes, and for the meta-analyses of individual modes of action. This heterogeneity could not be explained.

Authors' conclusions

Implications for practice

This review has found that compared with manual toothbrushes, powered toothbrushes are more effective than manual brushes in reducing plaque and gingivitis in the long and short term. An 11% reduction in plaque (Quigley Hein (Turesky) index) was shown at one to three months and a 21% reduction in plaque at longer than three months. With regard to gingivitis a 6% reduction (Löe Silness index) was seen at one to three months and a greater reduction of 11% in the long term. The clinical importance of these findings remains unclear.

Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and only temporary.

Implications for research

Trials of longer duration are required to fully evaluate the effects of powered toothbrushes. There are few trials reporting data over more than three months. Data on the long-term benefits of powered toothbrushes would be valuable in their own right and could be used to trial other outcomes such as the adverse effects and benefits in the prevention of periodontitis and dental caries.

This review continued to identify idiosyncrasies in the design of the trials and in some cases data could not be included for this reason. Whilst many of the trials were conducted before the current emphasis on experimental design, even recent trials lacked power calculations and had not been analysed on an intention-to-treat basis. Researchers in this field would be advised to study guidance on the design and reporting of clinical trials such as that provided in the CONSORT statement (http://www.consort-statement.org/) and Robinson and colleagues (Robinson 2006). Specific guidance exists for trials in the treatment or prevention of periodontal diseases (Imrey 1994) but greater standardisation of both the follow-up intervals and the indices used would benefit both trials and future meta-analyses. Thought should also be given to when the mouth should be examined in relation to when the teeth were last cleaned. Authors might also seek guidance on the analysis and presentation of cross-over trials.

Some research designs created an artificial research environment that may have undermined the generalis ability of the findings. In particular the external validity was questionable in trials with split-mouth designs where participants were asked to clean each side of their mouth with a different brush, in trials where interventions were used in combination and those where toothbrushing was supervised. Hence their exclusion from this meta-analysis.

More research with improved rigour is also needed on the relative benefits of powered and manual toothbrushes to prevent or remove extrinsic staining of the teeth and calculus.

Finally, empirical data on thresholds for clinically important differences in plaque and gingivitis levels would help to determine whether oral hygiene aids provide important health benefits.

Acknowledgements

Thanks are due to Anne Littlewood and Sylvia Bickley, Trials Search Co-ordinator for the Cochrane Oral Health Group for carrying out the searches for the review; Philip Riley and Liz Asbridge for administration of the review, co-ordination of databases and location of articles for the review; Luisa Fernandez Mauleffinch, Managing Editor for the Cochrane Oral Health Group for copy editing the review; and Bill Shaw and Mike Heanue for their contribution to previous versions of this review. For help with the translations of foreign papers our thanks go to Selva Can (German), Dr Mona Nasser (German), Dr Patrick Sequeira-Byron (German), Regina Mitezki (German), Paul Tramini (French), Professor Stéphanie Tubert-Jeannin (French) and Giovanni Lodi (Italian).
We would also like to thank the following investigators who replied to our requests for additional information about their trials: J de Boever (Universitair Ziekenhuis, Gent), C Burge (University of Colorado), M Darby (Old Dominion University), A Dentino (Marquette University), W Killoy (University of Missouri), A Koerber (University of Illinois), I Moschén (Leopold-Franzens-Universität), R Nolden (Rheinishe Friedrich-Wilhelms Universität), T Palmer (Clinical Research Associates), M Thompson (Gillette Company), P Warren (Gillette Company), AK Pelka (University Hospital of Munich), C Kossack (University of Berlin) and G.I MacCracken (Newcastle University). For their help as referees, we express our thanks to Martin Addy, Nik Barstow, Robin Davies, Marco Esposito, Eleanor Grey, Jayne Harrison, Lee Hooper, Ian Needleman, Richard Niederman, Derek Richards and Philip Riley.

Data and analyses

Download statistical data

Comparison 1. All powered toothbrushes versus manual toothbrushes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Plaque scores at 1 to 3 month at all sites402871Std. Mean Difference (IV, Random, 95% CI)-0.50 [-0.70, -0.31]
1.1 Quigley Hein (Turesky)282000Std. Mean Difference (IV, Random, 95% CI)-0.39 [-0.56, -0.22]
1.2 Silness and Löe6431Std. Mean Difference (IV, Random, 95% CI)-0.94 [-1.83, -0.05]
1.3 Visible plaque index Ainamo Bay1111Std. Mean Difference (IV, Random, 95% CI)-0.26 [-0.63, 0.12]
1.4 Ortho modification of Silness and Löe160Std. Mean Difference (IV, Random, 95% CI)0.0 [-0.51, 0.51]
1.5 Navy plaque index mod Rustogi3249Std. Mean Difference (IV, Random, 95% CI)-1.13 [-1.94, -0.31]
1.6 O'Leary index120Std. Mean Difference (IV, Random, 95% CI)-1.81 [-2.88, -0.73]
2 Gingival scores at 1 to 3 months at all sites443345Std. Mean Difference (IV, Random, 95% CI)-0.43 [-0.60, -0.25]
2.1 Löe and Silness302109Std. Mean Difference (IV, Random, 95% CI)-0.46 [-0.66, -0.25]
2.2 Lobene gingival index8907Std. Mean Difference (IV, Random, 95% CI)-0.43 [-0.88, 0.03]
2.3 BOP3159Std. Mean Difference (IV, Random, 95% CI)-0.19 [-0.50, 0.12]
2.4 Papillary bleeding index 0-4 scale295Std. Mean Difference (IV, Random, 95% CI)-0.11 [-1.55, 1.33]
2.5 BOMP 0-2 scale175Std. Mean Difference (IV, Random, 95% CI)-0.58 [-1.04, -0.12]
3 Plaque scores at >3 months14978Std. Mean Difference (IV, Random, 95% CI)-0.47 [-0.82, -0.11]
3.1 Quigley Hein (Turesky)11736Std. Mean Difference (IV, Random, 95% CI)-0.51 [-0.97, -0.04]
3.2 Silness and Löe2131Std. Mean Difference (IV, Random, 95% CI)-0.38 [-1.09, 0.34]
3.3 Visible plaque index Ainamo Bay1111Std. Mean Difference (IV, Random, 95% CI)-0.28 [-0.66, 0.09]
4 Gingival scores at >3 months161645Std. Mean Difference (IV, Fixed, 95% CI)-0.21 [-0.31, -0.12]
4.1 Löe and Silness5318Std. Mean Difference (IV, Fixed, 95% CI)-0.27 [-0.49, -0.05]
4.2 Lobene gingival index4440Std. Mean Difference (IV, Fixed, 95% CI)-0.14 [-0.33, 0.04]
4.3 BOP4270Std. Mean Difference (IV, Fixed, 95% CI)-0.46 [-0.70, -0.22]
4.4 Papillary bleeding index 0-4 scale132Std. Mean Difference (IV, Fixed, 95% CI)0.65 [-0.07, 1.36]
4.5 BOMP 0-2 scale175Std. Mean Difference (IV, Fixed, 95% CI)-0.24 [-0.69, 0.22]
4.6 PMA1510Std. Mean Difference (IV, Fixed, 95% CI)-0.16 [-0.34, 0.02]
Analysis 1.1.

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Analysis 1.2.

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Analysis 1.3.

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.

Analysis 1.4.

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Comparison 2. Side to side powered toothbrushes versus manual toothbrushes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Plaque scores at 1 to 3 month at all sites7570Std. Mean Difference (IV, Random, 95% CI)-0.27 [-0.77, 0.23]
1.1 Quigley Hein (Turesky)4324Std. Mean Difference (IV, Random, 95% CI)-0.14 [-0.36, 0.08]
1.2 Silness and Löe3246Std. Mean Difference (IV, Random, 95% CI)-0.78 [-2.25, 0.68]
2 Gingival scores at 1 to 3 months at all sites9795Std. Mean Difference (IV, Random, 95% CI)-0.32 [-0.81, 0.17]
2.1 Löe and Silness6385Std. Mean Difference (IV, Random, 95% CI)-0.28 [-0.88, 0.32]
2.2 Lobene gingival index3410Std. Mean Difference (IV, Random, 95% CI)-0.39 [-1.24, 0.46]
3 Plaque scores at >3 months3272Std. Mean Difference (IV, Fixed, 95% CI)0.02 [-0.21, 0.26]
3.1 Quigley Hein (Turesky)2218Std. Mean Difference (IV, Fixed, 95% CI)0.03 [-0.24, 0.30]
3.2 Silness and Löe154Std. Mean Difference (IV, Fixed, 95% CI)0.0 [-0.53, 0.53]
4 Gingival scores at >3 months3272Std. Mean Difference (IV, Fixed, 95% CI)0.10 [-0.14, 0.34]
4.1 Löe and Silness154Std. Mean Difference (IV, Fixed, 95% CI)0.0 [-0.53, 0.53]
4.2 Lobene gingival index1166Std. Mean Difference (IV, Fixed, 95% CI)0.16 [-0.14, 0.47]
4.3 BOP152Std. Mean Difference (IV, Fixed, 95% CI)0.0 [-0.54, 0.54]
Analysis 2.1.

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Analysis 2.2.

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Analysis 2.3.

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.

Analysis 2.4.

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Comparison 3. Counter oscillation powered toothbrushes versus manual toothbrushes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Plaque scores at 1 to 3 month at all sites4 Mean Difference (IV, Random, 95% CI)Subtotals only
1.1 Quigley Hein (Turesky)4184Mean Difference (IV, Random, 95% CI)-0.03 [-0.15, 0.10]
2 Gingivitis scores at 1 to 3 months at all sites4172Std. Mean Difference (IV, Fixed, 95% CI)0.01 [-0.30, 0.31]
2.1 Löe and Silness2103Std. Mean Difference (IV, Fixed, 95% CI)0.01 [-0.39, 0.40]
2.2 Lobene gingival index140Std. Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.65, 0.59]
2.3 BOP129Std. Mean Difference (IV, Fixed, 95% CI)0.06 [-0.68, 0.79]
3 Plaque scores at >3 months2 Mean Difference (IV, Fixed, 95% CI)Subtotals only
3.1 Quigley Hein (Turesky)269Mean Difference (IV, Fixed, 95% CI)-0.27 [-0.48, -0.07]
4 Gingival scores at >3 months269Std. Mean Difference (IV, Fixed, 95% CI)-0.19 [-0.66, 0.29]
4.1 Lobene gingival index140Std. Mean Difference (IV, Fixed, 95% CI)-0.18 [-0.80, 0.44]
4.2 BOP129Std. Mean Difference (IV, Fixed, 95% CI)-0.19 [-0.93, 0.54]
Analysis 3.1.

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Analysis 3.2.

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 2 Gingivitis scores at 1 to 3 months at all sites.

Analysis 3.3.

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.

Analysis 3.4.

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Comparison 4. Rotation oscillation powered toothbrushes versus manual toothbrushes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Plaque scores at 1 to 3 month at all sites201404Std. Mean Difference (IV, Random, 95% CI)-0.53 [-0.74, -0.31]
1.1 Quigley Hein (Turesky)13979Std. Mean Difference (IV, Random, 95% CI)-0.44 [-0.69, -0.20]
1.2 Silness and Löe2115Std. Mean Difference (IV, Random, 95% CI)-1.17 [-2.74, 0.40]
1.3 Visible plaque index Ainamo Bay1111Std. Mean Difference (IV, Random, 95% CI)-0.26 [-0.63, 0.12]
1.4 Ortho modification of Silness and Löe160Std. Mean Difference (IV, Random, 95% CI)0.0 [-0.51, 0.51]
1.5 Navy plaque index mod Rustogi2119Std. Mean Difference (IV, Random, 95% CI)-0.72 [-1.09, -0.35]
1.6 O'Leary index120Std. Mean Difference (IV, Random, 95% CI)-1.81 [-2.88, -0.73]
2 Gingival scores at 1 to 3 months at all sites211479Std. Mean Difference (IV, Random, 95% CI)-0.49 [-0.73, -0.26]
2.1 Löe and Silness14952Std. Mean Difference (IV, Random, 95% CI)-0.68 [-0.99, -0.38]
2.2 Lobene gingival index3290Std. Mean Difference (IV, Random, 95% CI)-0.11 [-0.46, 0.24]
2.3 BOP2130Std. Mean Difference (IV, Random, 95% CI)-0.25 [-0.59, 0.10]
2.4 Papillary bleeding index132Std. Mean Difference (IV, Random, 95% CI)0.65 [-0.07, 1.36]
2.5 BOMP 0-2 scale175Std. Mean Difference (IV, Random, 95% CI)-0.58 [-1.04, -0.12]
3 Plaque scores at >3 months7527Std. Mean Difference (IV, Random, 95% CI)-0.66 [-1.28, -0.03]
3.1 Quigley Hein (Turesky)5339Std. Mean Difference (IV, Random, 95% CI)-0.73 [-1.69, 0.24]
3.2 Silness and Löe177Std. Mean Difference (IV, Random, 95% CI)-0.73 [-1.19, -0.26]
3.3 Visible plaque index Ainamo Bay1111Std. Mean Difference (IV, Random, 95% CI)-0.28 [-0.66, 0.09]
4 Gingival scores at >3 months8684Std. Mean Difference (IV, Fixed, 95% CI)-0.35 [-0.50, -0.20]
4.1 Lobene gingival index2234Std. Mean Difference (IV, Fixed, 95% CI)-0.36 [-0.62, -0.10]
4.2 BOP2189Std. Mean Difference (IV, Fixed, 95% CI)-0.64 [-0.93, -0.34]
4.3 Löe and Silness2154Std. Mean Difference (IV, Fixed, 95% CI)-0.25 [-0.57, 0.07]
4.4 Papillary bleeding index 0-4 scale132Std. Mean Difference (IV, Fixed, 95% CI)0.65 [-0.07, 1.36]
4.5 BOMP 0-2 scale175Std. Mean Difference (IV, Fixed, 95% CI)-0.24 [-0.69, 0.22]
5 Rotation oscillation versus manual: data not suitable for meta-analysis  Other dataNo numeric data
Analysis 4.1.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Analysis 4.2.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Analysis 4.3.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.

Analysis 4.4.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Analysis 4.5.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 5 Rotation oscillation versus manual: data not suitable for meta-analysis.

Rotation oscillation versus manual: data not suitable for meta-analysis
StudyPlaqueGingivitis
Costa 2007No statistically significant pre-post differences shownNo statistically significant pre-post differences shown
Gugerli 2007"Subjects using a power toothbrush during initial treatment reduced supragingival plaque to lower levels...than subjects using a manual brush""Subjects using a power toothbrush ...showed significantly less bleeding on probing than subjects using a manual brush"
Zimmer 2005

Median change in Quigely-Hein at 4 weeks:

Powered (Cybersonic): 0.23

Powered (Braun 3D Excel): 0.07

Manual: 0.22

Median change in Quigely-Hein at 8 weeks:

Powered (Cybersonic): 0.41

Powered (Braun 3D Excel): 0.08

Manual: 0.35

All indices showed statistically significant reductions for both power
toothbrushes which were superior to the manual brush

Median change in papillary bleeding index at 4 weeks:

Powered (Cybersonic): 0.25

Powered (Braun 3D Excel): 0.02

Manual: 0.39

Median change in papillary bleeding index at 8 weeks:

Powered (Cybersonic): 0.36

Powered (Braun 3D Excel): 0.10

Manual: 0.61

Comparison 5. Circular powered toothbrushes versus manual toothbrushes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Plaque scores at 1 to 3 month at all sites2128Std. Mean Difference (IV, Fixed, 95% CI)-0.02 [-0.37, 0.33]
1.1 Quigley Hein (Turesky)2128Std. Mean Difference (IV, Fixed, 95% CI)-0.02 [-0.37, 0.33]
1.2 Silness and Löe00Std. Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
2 Gingival scores at 1 to 3 months at all sites2128Std. Mean Difference (IV, Fixed, 95% CI)-0.18 [-0.53, 0.17]
2.1 Löe and Silness163Std. Mean Difference (IV, Fixed, 95% CI)0.13 [-0.36, 0.63]
2.2 Lobene gingival index165Std. Mean Difference (IV, Fixed, 95% CI)-0.50 [-0.99, -0.00]
Analysis 5.1.

Comparison 5 Circular powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Analysis 5.2.

Comparison 5 Circular powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Comparison 6. Ionic toothbrushes versus manual toothbrushes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Plaque scores at 1 to 3 months3186Std. Mean Difference (IV, Fixed, 95% CI)-0.57 [-0.87, -0.27]
1.1 Quigley Hein (Turesky)2116Std. Mean Difference (IV, Fixed, 95% CI)-0.30 [-0.67, 0.06]
1.2 Silness and Löe170Std. Mean Difference (IV, Fixed, 95% CI)-1.07 [-1.57, -0.57]
2 Plaque scores at >3 months at all sites1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
2.1 Quigley Hein (Turesky)1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
3 Gingivitis at 1 to 3 months2116Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.04, 0.02]
3.1 Löe and Silness2116Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.04, 0.02]
4 Gingival scores at >3 months at all sites1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
4.1 Löe and Silness1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
5 Ionic versus manual: data not suitable for meta-analysis  Other dataNo numeric data
Analysis 6.1.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 months.

Analysis 6.2.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 2 Plaque scores at >3 months at all sites.

Analysis 6.3.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 3 Gingivitis at 1 to 3 months.

Analysis 6.4.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months at all sites.

Analysis 6.5.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 5 Ionic versus manual: data not suitable for meta-analysis.

Ionic versus manual: data not suitable for meta-analysis
StudyPlaqueGingivitis
Galgut 1996The electrically active toothbrushes better plaque removal than the inactive toothbrushes (6.5% more plaque removal at final visit)Not reported
Moreira 2007Frequency distribution for plaque zero at baseline and 28 days was 9.27+/- 10.14/17.75+/-9.60 and 8.42+/-10.43/16.79+/-8.93 for ionic and conventional toothbrushes respectivelyNot reported
Comparison 7. Ultrasonic powered toothbrushes versus manual toothbrushes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Plaque scores at 1 to 3 month at all sites4301Std. Mean Difference (IV, Fixed, 95% CI)-1.33 [-1.59, -1.07]
1.1 Quigley Hein (Turesky)3171Std. Mean Difference (IV, Fixed, 95% CI)-0.97 [-1.30, -0.63]
1.2 Navy plaque index mod Rustogi1130Std. Mean Difference (IV, Fixed, 95% CI)-1.89 [-2.30, -1.47]
2 Gingival scores at 1 to 3 months at all sites5354Std. Mean Difference (IV, Fixed, 95% CI)-0.99 [-1.21, -0.76]
2.1 Löe and Silness3161Std. Mean Difference (IV, Fixed, 95% CI)-0.56 [-0.88, -0.25]
2.2 Lobene gingival index1130Std. Mean Difference (IV, Fixed, 95% CI)-1.80 [-2.21, -1.39]
2.3 Papillary bleeding index 0-4 scale163Std. Mean Difference (IV, Fixed, 95% CI)-0.82 [-1.34, -0.31]
3 Plaque scores at >3 months at all sites1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
3.1 Quigley Hein1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
4 Gingival scores at >3 months1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
4.1 Löe and Silness1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
5 Ultrasonic versus manual: data not suitable for meta-analysis  Other dataNo numeric data
Analysis 7.1.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Analysis 7.2.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Analysis 7.3.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months at all sites.

Analysis 7.4.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Analysis 7.5.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 5 Ultrasonic versus manual: data not suitable for meta-analysis.

Ultrasonic versus manual: data not suitable for meta-analysis
StudyPlaqueGingivitis
Costa 2007"There was a significant difference for the ultrasonic/buccal group indicating that the ultrasonic brush improved plaque reduction on the buccal surfaces (p=0.007, Wilcoxon test)"Marginal bleeding: "No significant differences were noted in the nine subgroups (p>0.05, Wilcoxon test)"
Zimmer 2005"Improvements of the indices after 4 and 8 weeks were calculated for comparison between groups. After 4 and 8 weeks, with respect to all indices, the use of the power toothbrushes resulted in improvements which were statistically significant superior to what was found for the manual brush (p<0.001)." Results were presented as box-plots with medians and 25, 75 percentiles. Non-parametric tests have been used for the data analysis"Improvements of the indices after 4 and 8 weeks were calculated for comparison between groups. After 4 and 8 weeks, with respect to all indices, the use of the power toothbrushes resulted in improvements which were statistically significant superior to what was found for the manual brush (p<0.001)." Results were presented as box-plots with medians and 25, 75 percentiles. Non-parametric tests have been used for the data analysis
Comparison 8. Unknown or other action versus manual toothbrushes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Plaque scores at 1 to 3 months at all sites2 Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected
1.1 Quigley Hein (Turesky)2 Std. Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
2 Gingival scores at 1 to 3 months at all sites3 Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected
2.1 Löe and Sillness3 Std. Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
3 Gingival scores >3 months at all sites1 Mean Difference (IV, Fixed, 95% CI)Totals not selected
3.1 PMA1 Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]
Analysis 8.1.

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 months at all sites.

Analysis 8.2.

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Analysis 8.3.

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 3 Gingival scores >3 months at all sites.

Appendices

Appendix 1. Cochrane Oral Health Group's Trials Register search strategy

From January 2014, searches of the Cochrane Oral Health Group's Trials Register for this review were undertaken using the Cochrane Register of Studies and the search strategy below:

1 ((toothbrush* or tooth-brush* or "tooth brush*"):ti,ab) AND (INREGISTER)
2 ((manual or conventional or handbrush):ti,ab) AND (INREGISTER)
3 ((power* or mechanical* or electric* or electronic or ultrasonic* or sonic* or "motor driven" or "battery operated" or "battery power*" or automatic*):ti,ab) AND (INREGISTER)
4 (#1 and #2 and #3) AND (INREGISTER)

Previous searches of the Cochrane Oral Health Group's Trials Register were undertaken using the Procite software and the search strategy below:

(toothbrush* AND (manual or conventional or handbrush) AND (power* or mechanical* or electri* or electronic* or "motor driven" or ultrasonic* or automatic* or oscillat* or *sonic* or "counter rota*" or "battery operat" or battery-powered))

Appendix 2. Cochrane Central Register of Controlled Trials (CENTRAL) search strategy

#1 MeSH descriptor toothbrushing this term only
#2 toothbrush* in All Text
#3 ((tooth in All Text near/6 clean* in All Text) or (teeth in All Text near/6 clean* in All Text))
#4 (#1 or #2 or #3)
#5 (manual in All Text or conventional* in All Text or handbrush* in AllText)
#6 (power* in All Text or mechanical* in All Text or electric* in All Text or electronic in All Text or ultrasonic* in All Text or sonic* in All Text or "motor driven" in All Text or "battery operated" in All Text or "battery power*" in All Text or automatic* in All Text)
#7 (#4 and #5 and #6)

Appendix 3. MEDLINE (OVID) search strategy

1. exp Toothbrushing/
2. toothbrush$.mp.
3. ((tooth or teeth) adj3 clean$).mp.
4. or/1-3
5. manual$.mp.
6. conventional$.mp.
7. handbrush$.mp.
8. 5 or 6 or 7
9. power$.mp.
10. mechanical$.mp.
11. electronic$.mp.
12. electric$.mp.
13. ultrasonic$.mp.
14. sonic$.mp.
15. "motor driven".mp.
16. "battery operated".mp.
17. automatic$.mp.
18. or/9-17
19. 4 and 8 and 18

The above subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of theCochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 (updated March 2011) (Higgins 2011).

1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1-8
10. exp animals/ not humans.sh.
11. 9 not 10

Appendix 4. EMBASE (OVID) search strategy

1. Tooth brushing/
2. (toothbrush$ or (tooth adj brush$))
3. ((tooth or teeth) adj3 clean$)
4. 1 or 2 or 3
5. manual$
6. conventional$
7. handbrush$
8. 5 or 6 or 7
9. power$
10. mechanical$
11. electric$
12. electronic$
13. ultrasonic$
14. sonic$
15. "motor driven"
16. "battery operated"
17. automatic$
18. 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17
19. 4 and 8 and 18

The above subject search was linked to the Cochrane Oral Health Group filter for EMBASE via OVID:

1. random$.ti,ab.
2. factorial$.ti,ab.
3. (crossover$ or cross over$ or cross-over$).ti,ab.
4. placebo$.ti,ab.
5. (doubl$ adj blind$).ti,ab.
6. (singl$ adj blind$).ti,ab.
7. assign$.ti,ab.
8. allocat$.ti,ab.
9. volunteer$.ti,ab.
10. CROSSOVER PROCEDURE.sh.
11. DOUBLE-BLIND PROCEDURE.sh.
12. RANDOMIZED CONTROLLED TRIAL.sh.
13. SINGLE BLIND PROCEDURE.sh.
14. or/1-13
15. ANIMAL/ or NONHUMAN/ or ANIMAL EXPERIMENT/
16. HUMAN/
17. 16 and 15
18. 15 not 17
19. 14 not 18

Appendix 5. CINAHL (EBSCO) search strategy

S1 MH "Toothbrushing+"  
S2 toothbrush*  
S3 (tooth N3 clean*) or (teeth N3 clean*)  
S4 S1 or S2 or S3  
S5 manual*  
S6 conventional*  
S7 handbrush*  
S8 S5 or S6 or S7  
S9 power*  
S10 mechanical*  
S11 electric*  
S12 electronic*  
S13 ultrasonic*   
S14 sonic*  
S15 "motor driven"  
S16 "battery operated"  
S17 automatic*  
S18 S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17  
S19 S4 and S8 and S18  

The above subject search was linked to the Cochrane Oral Health Group filter for CINAHL via EBSCO

S1 MH Random Assignment or MH Single-blind Studies or MH Double-blind Studies or MH Triple-blind Studies or MH Crossover design or MH Factorial Design  
S2 TI ("multicentre study" or "multicenter study" or "multi-centre study" or "multi-center study") or AB ("multicentre study" or "multicenter study" or "multi-centre study" or "multi-center study") or SU ("multicentre study" or "multicenter study" or "multi-centre study" or "multi-center study")   
S3 TI random* or AB random*  
S4 AB "latin square" or TI "latin square" 
S5 TI (crossover or cross-over) or AB (crossover or cross-over) or SU (crossover or cross-over)  
S6 MH Placebos  
S7 AB (singl* or doubl* or trebl* or tripl*) or TI (singl* or doubl* or trebl* or tripl*)
S8 TI blind* or AB mask* or AB blind* or TI mask*  
S9 S7 and S8
S10 TI Placebo* or AB Placebo* or SU Placebo*  
S11 MH Clinical Trials 
S12 TI (Clinical AND Trial) or AB (Clinical AND Trial) or SU (Clinical AND Trial) 
S13 S1 or S2 or S3 or S4 or S5 or S6 or S9 or S10 or S11 or S12  

In a previous version of this review, the following search strategy was used for CINAHL via OVID:

1. exp toothbrushes/
2. toothbrush$
3. ((tooth or teeth) adj3 clean$)
4. 1 or 2 or 3
5. manual$
6. conventional$
7. handbrush$
8. 5 or 6 or 7
9. power$
10. mechanical$
11. electric$
12. electronic$
13. ultrasonic$
14. sonic$
15. "motor driven"
16. "battery operated"
17. automatic$
18. 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17
19. 4 and 8 and 18

Appendix 6. US National Institutes of Health Trials Register (ClinicalTrials.gov) and WHO International Trials Register Platform search strategy

toothbrush* AND electric*
toothbrush* AND power*

What's new

DateEventDescription
2 June 2014New search has been performedSearches updated to January 2014.
2 June 2014New citation required but conclusions have not changedThe review has been repeated 10 years after it was first completed. The update now includes 56 trials. 51 trials involving 4624 participants were available for meta-analysis. The update has findings consistent with the previous reviews that powered toothbrushes with a rotation oscillation action are more effective than manual brushes at removing plaque and reducing gingivitis.

History

Protocol first published: Issue 2, 2000
Review first published: Issue 1, 2003

DateEventDescription
20 August 2008AmendedConverted to new review format.
17 February 2005New search has been performedThis review has been repeated, 2 years after it was first completed. The original review included 29 trials involving 2547 subjects. 42 trials are now included, involving 3855 participants.
17 February 2005New citation required and conclusions have changedSubstantive amendment.
More studies have been included for brushes that work with a rotation oscillation action. The update confirms that these brushes removed more plaque and reduced gingivitis more effectively than manual brushes in the short term. Brushes of this design reduced gingivitis scores over 3 months.
A refinement of the data analysis for brushes that work with a rotation oscillation action excluded 1 study from the current review for plaque over 3 months. Excluding this study does not substantially change our estimate of the treatment effect. However, because there are fewer studies in the analysis the 95% confidence intervals are wider and the findings are no longer statistically significant for this analysis.
Trials of ionic brushes that impart a charge to the tooth surface have been included for the first time. The analyses show no benefit from these brushes on plaque or gingivitis in studies lasting 1 to 3 months but effects in studies over 3 months. This inconsistency cannot be explained but only 1 study was included in the long-term analyses.

Contributions of authors

Bill Shaw and Helen Worthington wrote the protocol. Anne-Marie Glenny, Bill Shaw, Mike Heanue, Peter Robinson, Damien Walmsley and Munirah Yaacob co-ordinated the review. Bill Shaw and Peter Robinson wrote the letters to the authors. Bill Shaw, Scott Deacon, Chris Deery, Mike Heanue, Peter Robinson, Damien Walmsley and Munirah Yaacob independently and in duplicate assessed the eligibility of trials, extracted data and assessed the quality of the trials. Damien Walmsley and Peter Robinson provided the background and sourced information on brush action and plaque and gingival indices. Helen Worthington conducted the statistical analysis. Scott Deacon, Anne-Marie Glenny, Munirah Yaacob and Mike Heanue checked and entered data. Anne-Mare Glenny, Helen Worthington and Munirah Yaacob wrote this version of the review, and checked for numerical consistency. Chris Deery updated the background.

Declarations of interest

Bill Shaw and Helen Worthington were co-researchers on a randomised controlled trial sponsored by Braun AG (Clerehugh 1998) through a grant to The University of Manchester. Damien Walmsley was a consultant and undertook laboratory trials of powered toothbrushes sponsored by Braun AG through a grant to the University of Birmingham.

Sources of support

Internal sources

  • School of Dentistry, The University of Manchester, UK.

  • School of Dentistry, The University of Birmingham, UK.

  • Edinburgh Dental Institute, UK.

  • University of Sheffield, School of Dentistry, UK.

  • MAHSC, UK.

    The Cochrane Oral Health Group is supported by the Manchester Academic Health Sciences Centre (MAHSC) and the NIHR Manchester Biomedical Research Centre.

External sources

  • Cochrane Oral Health Group Global Alliance, UK.

    All reviews in the Cochrane Oral Health Group are supported by Global Alliance member organisations (British Association of Oral Surgeons, UK; British Orthodontic Society, UK; British Society of Paediatric Dentistry, UK; British Society of Periodontology, UK; Canadian Dental Hygienists Association, Canada; Mayo Clinic, USA; National Center for Dental Hygiene Research & Practice, USA; New York University College of Dentistry, USA; and Royal College of Surgeons of Edinburgh, UK) providing funding for the editorial process (http://ohg.cochrane.org/).

  • National Institute for Health Research (NIHR), UK.

    CRG funding acknowledgement:
    The NIHR is the largest single funder of the Cochrane Oral Health Group.

    Disclaimer:
    The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Ainamo 1997

MethodsRCT, parallel, single blind, 12 months, n = 112 with 1 drop-out.
ParticipantsFinland, adults, 20 to 63 years, 64 M 47 F, bleeding on probing >30% sites, no medical problems.
InterventionsBraun Oral B Plak Control versus Jordan soft, 2 min twice daily. Use of timer not stated.
OutcomesAinamo and Bay Visible plaque index and modified gingival bleeding index. 3, 6 and 12 months. Whole mouth recording PI and GI.
NotesNo pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "The study was randomised..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "... parallel group, single blind (to examiner), with a duration of 12 months."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 1/112. 1 withdrew from the electric toothbrush group for personal (non-clinical) reasons before the 3-month assessment. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Baab 1989

MethodsRCT, parallel, single blind, 1 month, n = 41, with 2 drop-outs.
ParticipantsUSA, adults, 18 to 59 years, 24 M:16 F, >20 teeth with moderate gingivitis, no medical problems.
InterventionsInterplak versus Butler 411, 3 min twice daily. Use of timer not stated.
OutcomesO'Leary plaque index, Löe and Silness gingival index, Ainamo and Bay gingival bleeding index. Ramfjord teeth for GI, whole mouth for PI. Gingival abrasion reported to be not significant. Plaque scores awaiting assessment.
NotesManufacturer funded.
No pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned.."

Insufficient information.

Allocation concealment (selection bias)Low riskQuote: "....The manufacturer provided 20 Interplak electric toothbrushes and 20 Butler 411 toothbrushes... arranged randomly in consecutively-numbered boxes."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...One investigator (DAB) served as the blind examiner and made all clinical..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 2/41. 1 participant did not comply (manual) and 1 other withdrew from study (electric). Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Barnes 1993

MethodsRCT, parallel, single blind, 3 months, n = 70 with 1 drop-out.
ParticipantsUSA, adults, 18 to 65 years, >20 teeth, gingival index >1.5, plaque index >2.
InterventionsBraun Oral B Plaque Remover versus Johnson & Johnson Reach, as per normal use.
OutcomesQuigley Hein (Turesky) plaque index, Löe and Silness (Lobene) gingival index at full mouth sites. Soft tissue trauma, no difference between brushes. Whole mouth recording PI and GI.
NotesManufacturer funded.
No pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned.."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All clinical examinations were performed by the same evaluator. This study was conducted in a single-blind manner."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 1/70. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Biavati Silvestrini 2010

MethodsRCT, parallel, 8 weeks, n = 20, no drop-outs, F 12:M 8.
ParticipantsItaly, orthodontic patients, 10 to 14 years with permanent dentition, scheduled to receive multibracket.
InterventionsOral B 35 versus Oral B Pro Care 8500, 2 min twice daily.
OutcomesO'Leary plaque index, Ainamo and Bay index, unsure full mouth sites or partial mouth score, not monitored compliance and adverse event.
NotesSource of funding unclear, no pre-examination instruction reported, low number of subjects.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly divided..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information.
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdeqaute reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Biesbrock 2007

MethodsRCT, parallel, single blind, 8 weeks, n = 179 with 5 drop-outs in full trial (n = 59 for powered versus manual comparison).
ParticipantsUnited States, adults, 18 to 69 years, ≥15 sites with bleeding on probing.
InterventionsOral B Pro Care series versus Oral B Cross Action, 2 min twice daily, use of timer not stated.
OutcomesRustogi Mod of the Navy plaque index, Löe & Sillness gingival index at 0 and 8 weeks. Whole mouth recording of plaque and gingivitis. Adverse event reported; no different between groups.
Notes

Manufacturer funded.

This is a trial of 2 manual groups with different toothpaste. 3 other groups with numerous combinations - 2 powered toothbrushes and mouthwash were also assessed. We used the comparison of manual and powered using the same toothpaste. Pre-intervention prophylaxis done. Pre-examination instruction given; no brushing for 12 hours and no drinking, no eating or tobacco for 4 hours.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "Eligible subjects were stratified based on gender and the number of baseline sites (≤40 or ≥41), and randomly assigned to ....."

Insufficient information.

Allocation concealment (selection bias)Low riskQuote: "... all test products were distributed in blinded kit boxes...."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "... all clinical assessment (efficacy and safety) were conducted by examiners who were blinded as to treatment assignment."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 1/59. None due to product-related adverse events. Unlikely influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Clerehugh 1998

MethodsRCT, parallel, single blind, 8 weeks, n = 84 with 5 drop-outs.
ParticipantsUK, children and adolescents, 10 to 20 years, orthodontic patients in practice, fixed appliances, gingival bleeding at 30% sites, no medical conditions.
InterventionsBraun Plaque Remover with OD 5 head versus Reach medium compact head, 2 min twice daily. Timer used.
OutcomesOrthodontic modification of Silness and Löe plaque index, Eastman bleeding index at all buccal sites at 4, 8 weeks. No evidence of trauma. 1 mechanical brush failed.
NotesManufacturer funded.
Participants asked to brush in the morning and under supervision prior to assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "...subjects were randomly allocated to groups using the minimisation methods..."
Allocation concealment (selection bias)Low riskQuote: "..and the clinical trial investigator remained blind to the toothbrush group allocation."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: " ..and the clinical trial investigator remained blind to the toothbrush group allocation."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 5/84 completed. Reason for drop-outs: electric toothbrush group (37/41) - 1 failed to attend final examination, 1 failed to follow brushing instruction, 1 failed to use the product for 7 days prior to the week 4 examination, 1 was put on tetracycline; manual group (42/43) - 1 developed chicken pox and could not attend for examination. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Costa 2007

MethodsRCT, single blind, cross-over, n = 21 with no drop-outs, 30 days (15 days wash-out period).
ParticipantsBrazil, orthodontics patients, aged 12 to 18 years, at least 20 teeth assessable, orthodontic treatment a minimum of 1 year, non-smokers with no history of periodontal disease.
InterventionsUltrasonex Ultima versus Oral B 3D versus Oral B Model 30, 2 min 3 times daily, use of timer not stated.
OutcomesSillness and Löe plaque indices, Löe and sillness gingival indices, microbiological parameters assessed, no difference in clinical and microbiological parameters. No adverse effect reported.
NotesFunding unclear, pre-intervention prophylaxis done.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly divided into three groups ...."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information.
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Cronin 1998

MethodsRCT, parallel, single blind, 3 months, n = 114, 9 drop-outs.
ParticipantsUSA, adults, >18 teeth, no medical problems, 18 to 65 years.
InterventionsBraun Oral B 3D Plaque Remover versus standard ADA reference manual, 2 min twice daily. Timer used.
OutcomesQuigley Hein (Turesky) plaque index, Löe and Silness gingivitis and bleeding index, at 14, 35 and 90 days, at all sites. Gingival recession recorded, no change seen. No other adverse effects. Whole mouth recording PI and GI.
NotesManufacturer funded.
Participants asked to refrain from brushing 12 to 14 hours prior to assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskRandomly assigned to 2 groups by Zelen's method of permuted blocks of size 4.
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..all subject were evaluated by the same examiner who was unaware of the type of toothbrush used by the subject."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 9/114 completed. Reasons for drop-outs: powered group - 8 with reasons unrelated to treatment; manual group - 1 failed to return for final examination. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Dentino 2002

MethodsRCT, parallel, single blind, 6 months, n = 172 with 15 drop-outs.
ParticipantsUSA, adults, mild to moderate gingivitis with >20 teeth, no previous powered brush experience. Excluded if pregnant/lactating.
InterventionsBraun Oral B D9 versus ADA accepted standard soft bristle manual, 2 min twice daily. Use of timer not stated.
OutcomesQuigley Hein (Turesky) plaque index and Lobene gingival index at 3 and 6 months. Powered brush removed more calculus. No difference in stain removal reported. PI and GI whole mouth.
NotesManufacturer funded.
Participants asked to brush teeth (non-supervised) immediately prior to 6-month plaque assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "Based on the screening visits, patients were stratified by gender, MGI, plaque index (PI), and smoking using a computer program, and were randomly assigned..."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "This 6-month, single-masked, parallel design.."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs: 15/172 but unclear as to which group these were from.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Dorfer 2009

MethodsRCT, parallel, single blind, 6 months, n = 109 with 3 drop-outs.
ParticipantsGermany, adult with recession, 18 to 70 years, ≥18 teeth present, ≥2 sites with at least 2 mm recession.
InterventionsOral B 7000 (D17) versus ADA toothbrush, 2 min twice daily, use of timer not stated.
OutcomesTuresky modified Quigley Hein plaque indices and gingivitis indices at 0, 6 months. Whole mouth recording of plaque and gingivitis. Main outcome measured was gingival recession; reduced pre-existing gingival recession in both groups. Other outcomes: PPD, PAL. Adverse event reported; no different between both groups. All patients reported to be compliant.
Notes

Manufacturer funded.

Pre-intervention instruction on use of each toothbrushes done. Matched or stratified groups.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "prospective randomized, controlled ..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...examiner blind.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 3/109. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Emling 1991

MethodsRCT, parallel, single blind, 30 days, n = 60 with 3 drop-outs.
ParticipantsUSA, adults, no medical problems, no current ortho, not pregnant, >17 teeth, 18 to 60 years.
InterventionsPlak Trac versus Colgate ADA approved, twice daily. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) plaque index. Yankell, interproximal plaque index, Löe and Sillness gingival index. Ramfjord teeth for both PI and GI.
NotesPre-brushing measurements used.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned ...."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The study was thus conducted in a single-blind manner."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 3/60.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Forgas-B 1998

MethodsRCT, parallel, single blind, 30 days, n = 62 with 6 drop-outs.
ParticipantsUSA, adults, mean age 37 years +/- 10 years, >16 teeth, plaque index >2, no medical problems, 21 M:35 F.
InterventionsUltrasonex versus manual Oral B, twice daily. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) plaque index, Eastman gingival bleeding index at 30 days. Ramfjord teeth for PI and GI. Soft tissue trauma reported, no difference between groups.
NotesManufacturer funded.
Participants asked to refrain from brushing for 12 to 14 hours before assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned ...."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Examiners were blind to group assignment."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs: 6/62 (5 from manual group; 1 from powered group). Uneven drop-outs across groups; reasons not stated.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Galgut 1996

MethodsRCT, parallel, single blind, 28 days, n = 70 with 7 drop-outs.
ParticipantsUK, Caucasians, male, 19 to 36 years.
InterventionsSangi Co Electronic (Active) versus Sangi Co Electronic (non-active), 3 minutes when brushing. No frequency stated. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) plaque index, Löe and Silness gingival index at 2, 4 weeks. Whole mouth recording for indices. No adverse events recorded.
NotesManufacturer funded. Assessment after 24 hours of no brushing.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk

Quote: "The company supplied 75 toothbrushes, numbered 1 to 75. Some ...were electrically active, and others...inactive" "Subjects received a trial toothbrush in numerical order.."

Not explicit but probably appropriate method.

Allocation concealment (selection bias)Low riskQuote: "Subjects received a trial toothbrush in numerical order..." "After completion of the clinical trial, coding ...was revealed to the primary investigator."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..toothbrushes were indistinguishable by anyone concerned with the clinical trial...."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs: 7/70. Unclear as to drop-outs by group.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Garcia-Godoy 2001

MethodsRCT, parallel, single blind, 30 days, n = 70 with 4 drop-outs.
ParticipantsUSA, children, 6 to 11 years, able to understand procedure.
InterventionsBraun Oral B D10 per manufacturers instructions versus ADA approved manual brush as normal.
OutcomesQuigley Hein (Turesky) plaque index. Whole mouth. No adverse events recorded.
NotesManufacturer funded. Assessment after 12 to 18 hours from last brushing.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomized to..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...conducted by the same examiner who was blinded to the treatment group."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 4/70. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Glass 1965

MethodsRCT, parallel, single blind, 11 months, n = 250 with 84 drop-outs.
ParticipantsUSA, dental students, male, 20 to 29 years.
InterventionsGEC powered versus Pycopay brand manual twice daily. Use of timer not stated.
OutcomesGlass debris and gingival indices at 6 weeks, 7 and 11 months at all sites. Stain and calculus reported to be no different between brush types. Whole mouth recording PI and GI. No soft tissue trauma reported.
NotesManufacturer funded.
No pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "A random, binary digit was punched by a computer into each name card to provide identification of two groups" "A coin was tossed to determine the assignment of brushes."
Allocation concealment (selection bias)Low riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..the examiner was unaware of the brush type used by the subject."
Incomplete outcome data (attrition bias)
All outcomes
High riskDrop-outs: 84/250 drop-outs. Unclear of drop-outs by group; could influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Goyal 2007

MethodsRCT, parallel, single blind, 30 days, n = 53 with no drop-outs.
ParticipantsCanada, adults, 18 to 65 years, Löe and Sillness gingival index ≥ 1.5.
InterventionsUltreo Versus Oral B 35, twice daily, period of brushing not stated, use of timer not stated.
OutcomesLöe and Silness gingival indices at 0, 30 days at all sites. Whole mouth. Adverse event reported; no different between groups. Subjective experience of cleanliness assessed revealed higher score in Ultreo group. No adverse event reported.
Notes

Manufacturer funded.

No pre-intervention treatment and pre-examination instruction given.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned ...."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: " ..was a randomised, examiner blind, parallel..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Gugerli 2007

MethodsRCT, parallel, single blind, 28 days, n = 70 with no drop-outs.
ParticipantsSwitzerland, adults, 18 to 70 years, M 46 F 46, minimun of 12 score able teeth, chronic periodontitis, Class II, good general health.
InterventionsOral B Pro Care 8000 versus ADA, twice daily, period of brushing not stated, use of timer not stated.
OutcomesSillness and Löe plaque indices and Löe and Sillness gingival indices at 0, 28 days at all sites. Whole mouth recording of plaque and gingival indices. Compliance recorded in diaries. Abrasion reported in 3 patients of each groups.
Notes

Manufacturer funded.

Pre-intervention prophylaxis done, pre-intervention instructions on oral hygiene given for 15 min.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "Subjects were assigned randomly by a computer-generated table..."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "This was an examiner-masked..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Haffajee 2001a

MethodsRCT, parallel, single blind, 6 months, n = 52 with 4 drop-outs.
ParticipantsUSA, systemically healthy participants with adult periodontitis, 20 to 64 years, minimum of 20 teeth.
InterventionsCrest Complete versus Braun Oral B D15 Plaque Remover. Frequency unclear. Use of timer not stated.
OutcomesTuresky plaque index , Löe and Silness gingival index, bleeding on probing and probing attachment level at baseline, 3 and 6 months. Measurements taken for 6 sites per tooth for up to 28 teeth.
NotesManufacturer funded.
No pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: " ..toothbrushing group using a pre-determined randomisation schedule."
Allocation concealment (selection bias)Low riskQuote: " A copy of randomization schedule and study codes were kept by the principal investigator."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "In this 6 months, single-blind study,..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 4/52. Reasons for drop-outs: moving away from the area, did not want to use toothpaste provided and reasons unrelated to study. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Heasman 1999

MethodsRCT, parallel, single blind, 6 weeks, n = 75 with 1 drop-out.
ParticipantsUK, adults, >permanent 20 teeth, 18 to 25 years, no medical problems.
InterventionsBraun Oral B D7 versus Philips Jordan HP 735 versus Oral B Advantage B35, >90 seconds twice daily. Use of timer not stated.
OutcomesQuigley Hein (Turesky) plaque index at 24 hours and 6 weeks, Löe and Silness gingival index at 6 weeks, all sites.
Whole mouth recording PI and GI.
NotesAssessment done within 3 to 4 hours of last brushing.
2 powered groups combined for meta-analysis.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskQuote: "...allocated ranomly..."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..single-blind clinical trial was undertaken.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 1/75. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Hickman 2002

MethodsRCT, parallel, blinding unclear, 8 weeks, n = 63 with 3 drop-outs.
ParticipantsUK, orthodontic patients, 10 to 20 years, medically fit.
InterventionsBraun Plaque Remover 3D with orthodontic head versus Reach compact head manual, 2 min twice daily. Timer supplied.
OutcomesSilness and Löe plaque index (orthodontic modification) and Löe and Silness gingival index, full mouth at 4 and 8 weeks.
NotesManufacturer funded. Brush as normal post-breakfast.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk

Quote: "...randomly assigned...", "...prepared by the trial statistician..."

Sequence generation not explicit, but assumed low risk of bias.

Allocation concealment (selection bias)Unclear risk

Quote: "The trial coordinator who opened a sealed envelopes, prepared by the trial statistician, containing the group allocation, undertook randomization."

Unclear if sealed envelopes were sequentially numbered.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The trial researcher was blinded to the group allocation.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 3/63. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Ho 1997

MethodsRCT, parallel, single blind, 4 weeks, n = 24, drop-outs unclear.
ParticipantsUSA, orthodontic patients, with fixed appliances, 11 to 18 years, gingival index >2, no medical conditions.
InterventionsSonicare Ultrasonic versus Oral B P35, 2 min twice daily. Timer supplied.
OutcomesSilness and Löe gingival and plaque indices on 6 sites per bonded tooth and bleeding on probing all at 4 weeks. Whole mouth recording PI and GI.
NotesManufacturer funded.
No pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "..subjects to the two groups was done through use of two tables of random numbers."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "A single investigator (HH), who was blinded as to which toothbrush was being used.."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs unclear.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Johnson 1994

MethodsRCT, parallel, single blind, 4 weeks, n = 53 with 10 drop-outs.
ParticipantsUSA, adults, >20 teeth, gingival index >1.5 on Ramjford teeth, no medical conditions, 20 to 54 years.
InterventionsPhilips Sonicare versus Oral B 30, 2 min twice daily. Timer supplied.
OutcomesQuigley Hein (Turesky) on all sites, Ainamo and Bay gingival index and sulcular bleeding indices on Ramfjord at 1, 2, 4 weeks. Soft tissue trauma "abnormalities" 7 sites in 6 subjects for manual and 10 sites in 7 subjects for powered.
NotesManufacturer funded.
Post-brushing evaluation.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned...."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..randomised, single-blind, controlled clinical study."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 10/53. Even drop-outs, due to missed visits. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Kallar 2011

MethodsRCT, parallel, 12 weeks, n = 200 and unsure of drop-outs (assume no drop-outs).
ParticipantsIndia, school children aged 6 to 13 years.
InterventionsUnknown powered versus unknown manual toothbrush, no information on methods, time and duration of brushing.
OutcomesTuresky Quigley Hein plaque index on all sites, full mouth at 3, 6, 9 and 12 weeks.
Notes

Funding source not stated.

Mix of supervised and unsupervised brushing.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "Children were randomly divided into two groups."

Insufficient information

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskUnclear but assumed no drop-outs.
Selective reporting (reporting bias)High riskGingivitis not reported.
Other biasUnclear riskUnclear as little text in the report.

Khocht 1992

MethodsRCT, parallel, single blind, 4 weeks, n = 96 with 1 drop-out.
ParticipantsUSA, adults, >15 teeth with no restorations affecting cervical region plaque score >1.8 and gingival score >0.9, no medical conditions.
InterventionsEpident and Interplak versus Oral B 40, twice daily. Use of timer not stated.
OutcomesQuigley Hein (Turesky) plaque index and Löe and Silness gingivitis index at all sites at 28 days. Whole mouth recording for PI and GI. No reported soft tissue abrasion.
NotesManufacturer funded.
Pre-brushing evaluation.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned...."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "This single (examiner) blind.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 1/96. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Lapiere unpublished

MethodsRCT, parallel, single blind, 12 weeks, n = 48 with no drop-outs stated.
ParticipantsBelgium, periodontal patients, 18 to 65 years, 20 natural teeth, no removable dentures, probing pocket depth >2 mm but <5 mm, free from subgingival calculus.
InterventionsPhilips HP 550 versus P Oral B 35 versus Braun Oral B D5, 2 min 3 times a day. Use of timer not stated.
OutcomesQuigley Hein (Turesky) plaque index and Löe and Silness gingivitis index, whole mouth at 12 weeks.
NotesFunding unclear. No pre-examination instructions reported.
Data for 2 powered brushes combined as same mode of action.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskOnly mentions randomised. Insufficient information.
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Everything was done to keep the whole procedure as blinded as possible."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Lazarescu 2003

MethodsRCT, parallel, single blind, 18 weeks, n = 80 with 2 drop-outs.
ParticipantsRomania, adults, >20 teeth, medically fit and no previous powered brush experience.
InterventionsPhilips/Jordan HP 735 versus Oral B 40 manual with normal brushing pattern. Use of timer not stated.
OutcomesQuigley Hein (Turesky) plaque index at 6 sites per tooth and gingival bleeding index at proximal smooth surfaces at 18 weeks. Whole mouth recording PI and GI.
NotesManufacturer funded.
Assumed pre-brushing evaluation.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskQuote: "..subjects were divided into two groups by an independent examiner not taking part in the further clinical assessment."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The investigator were blinded to the toothbrush used by the subjects."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 2/80. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Lobene 1964a

MethodsRCT, parallel, single blind, n = 185, 3 months, drop-outs unclear.
ParticipantsUSA, female college students, aged 17 to 21 years.
InterventionsGeneral electric reciprocating action versus Oral B 40 manual with no instruction. Use of timer not stated.
OutcomesLobene gingivitis index at 3 months. Whole mouth recording PI and GI.
NotesManufacturer funded.
No pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskOnly mentions randomised. Insufficient information.
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..the examiner was unaware of the group to which any subject was assigned."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs unclear.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

McCracken 2004

MethodsRCT, parallel, single blind, 16 months, n = 40 with 8 drop-outs.
ParticipantsUK, patients who attended periodontal clinic, 25 to 70 years, periodontal disease identified clinically by minimum of 10 sites with PPD ≥5 mm confirmed by radiograph, full mouth plaque score at least 2.0, minimum of 20 permanent teeth. Excluded: previous use of powered toothbrush.
InterventionsPhilip Sensiflex 2000 brand versus Oral B Advantage. 2 min twice daily, use of timer not stated.
OutcomesTuresky modified Quigley Hein plaque indices and Papilla bleeding indices at 0, 3, 10, 16 months, whole mouth recordings. Other outcomes: pocket depth reported: no different between both groups. Soft tissue lesion (abrasion and ulcer) reported; 8 in manual and 5 in powered.
Notes

Manufacturer funded.

Pre-intervention prophylaxis at baseline. No prophylaxis done at different visit. Use of interdental cleaning was recommended for at least once a day.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "A numerically balanced, stratified (for gender,age,smoking status) and randomised allocation of patients produced two groups..", "A 75% weighted randomisation was used to balance the distribution of the stratification characteristics between the groups."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "A two group, parallel, single blind...."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 8/40. Even distribution of drop-outs and reasons not linked to interventions. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

McCracken 2009

MethodsRCT, parallel, single blind, 12 months, n = 60 with 8 drop-outs.
ParticipantsUK, periodontal patients from dental hospital, 18 to 45 years, localised areas of buccal/labial gingival recession with at least 1 mm attachment loss with Miller classification I and II recession defects. Excluded: moderate to severe chronic and agressive periodontitis and routinely using powered toothbrushes.
InterventionsPhilips Sonicare Elite versus Oral B 35. 2 min twice daily, use of timer not stated.
OutcomesTuresky modified Quigley Hein plaque indices and bleeding on probing (dichotomous) at 0, 3, 6, 9 and 12 months. Whole mouth. Other outcomes on CAL, PD, recession, wear of the brushes reported; no differences between both groups. Adverse events reported not related to studies; 18 in manual and 16 in powered groups.
Notes

Manufacturer funded.

Pre-intervention prophylaxis and instruction done. Reinforced oral hygiene at each visits.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "The randomization sequence was generated using SPSS (version 14) using a block methodology..."
Allocation concealment (selection bias)Low riskQuote: "This remained concealed until the time of brush allocation..."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "two clinical examiners remained blinded to group allocation.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 8/60. Even distribution of drop-outs and reasons not linked to interventions. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Moreira 2007

MethodsRCT, cross-over, single blind, 28 days, n = 20 with no drop-outs, 14 days wash-out period.
ParticipantsBrazil, first year dental students, 18-29 years old, 15 F 5 M, at least 20 teeth present, right handed subjects, 15% plaque visible at buccal and lingual surfaces. Excluded: subjects with orthodontics appliances, taking any medication would interfere plaque formation and antibiotics treatment during the 3/12 prior to study.
InterventionsHyG ionic versus Close-up Essential, 2 min twice daily. Use of timer not stated.
OutcomesTuresky modified Quigley Hein plaque indices and gingival bleeding indices (Ainamo and Bay dichotomomization of the Löe gingival index) at 0 and 28 days. Full mouth score. No difference between groups. Adverse event reported in later study (Moreira 2008); no differences between groups.
Notes

No external funding for initial study. Scholarship by CAPES acknowledged in Moreira 2008.

Pre-intervention prophylaxis at baseline and between wash-out period. Refrained oral hygiene 10-12 hours prior to examination.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "..after the examination and by means of the flip of a coin, individuals were assigned to either one of the two toothbrushes..."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...blinded calibrated examiner..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Moritis 2008

MethodsRCT, parallel, single blind, 4 weeks, n = 180 with 12 drop-outs.
ParticipantsUK, adults, 18 to 65 years, 142 F 27 M, non-smokers with at least 20 natural teeth, gingival index of ≥2.0 on at least 20 sites and plaque index of ≥0.8, excluded: severe gingivitis and periodontitis.
InterventionsSonicare Elite versus manual. 2 min twice daily. Use of timer not stated.
OutcomesSillness and Löe plaque indices and Löe and Sillness gingival indices at 0, 2, 4 weeks. Whole mouth. Abrasion reported: 1 in manual and 1 in powered. Compliance monitored at average subjects brushed 2 min twice daily. Adversed events not reported.
Notes

Manufacturer funded.

No pre-intervention treatment. Refrained from oral hygiene for 2 to 6 hours before baseline examination.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned...."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...examiner calibrated and blinded to product assignment."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 12/180. 4 lost to follow-up, 5 drop-outs due to adverse event not related to study, 3 scheduling conflicts.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

O'Beirne 1996

MethodsRCT, parallel, single blind, 8 weeks, n = 40, drop-outs unclear.
ParticipantsUSA, adults with inflammatory periodontal disease, >20 teeth and received periodontal treatment, 22 M: 18 F, 18 to 65 years.
InterventionsSonicare Ultrasonex versus Oral B manual 2 min twice daily. Timer supplied.
OutcomesLöe and Silness gingival index, Barnett papillary bleeding index at 2, 4 and 8 weeks, at all sites. Whole mouth recording PI and GI. Minor gingival trauma seen in 1 participant in each group.
NotesPart funded by manufacturer.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskQuote: " devices were packaged in kits, arranged in random order and numbered in sequence by the sponsoring company, independednt of the investigators."
Allocation concealment (selection bias)Low riskQuote: " devices were packaged in kits, arranged in random order and numbered in sequence by the sponsoring company, independednt of the investigators."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: " ..single-blinded, randomised clinical investigation.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Pucher 1999

MethodsRCT, parallel, double blind, 6 weeks, n = 60 with 8 drop-outs.
ParticipantsUSA, orthodontic patients, >20 teeth, >12 years, 23 M: 29 F after drop-outs.
InterventionsHukuba ionic (active) versus Hukuba ionic (non-active) with usual technique twice daily. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) plaque index, Löe and Silness gingival index, whole mouth at 6 weeks. No adverse events/effects recorded.
NotesFunding not stated. No brushing for 12 hours and pre-brushing data used.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "..randomly assigned.."

Insufficient information.

Allocation concealment (selection bias)Low riskQuote: "The patients were given a prepackaged, coded toothbrush."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "...both participants and the examiner were unaware of which toothbrush the participants were using during..."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs: 8/60. Unclear as to which group drop-outs came from.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Rosema 2008

MethodsRCT, parallel, single blind, 9 months, n = 118 with 4 drop-outs.
ParticipantsNertherlands, general population (with intensive pre-intervention oral hygiene care), aged ≥18 years, minimun of 5 evaluable teeth per quadrant, gingival bleeding ≥40%, absence of oral lesion. No pocket depth >5 mm, no wearing partial denture, orthodontic wires.
InterventionsOral B D25 Pro Care 9000 versus ADA toothbrush, 2 min twice daily. Use of timer.
OutcomesModified Quigley and Hein plaque indices, partial mouth score, bleeding on marginal probing index (BOMP 0-2 scale) at 0, 10 weeks, 6 and 9 months. Powered toothbrush maintained lower plaque levels for 9 months better than manual toothbrush. No adverse events reported.
NotesManufacturer funded. Pre-intervention: very intensive oral home care for 3 weeks. Pre-intervention prophylaxis at baseline, reinforced oral hygiene intervention at 6 and 10 months.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "Randomization was performed using true random numbers generated by ..."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "... examiner masked..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 4/118. Even distribution of drop-outs and reasons not linked to interventions. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskThe subjects who smoked were not balanced between the groups; 5 for manual group and 2 only for powered group but unlikely to influence results.

Sharma 2000

MethodsRCT, parallel, single blind, 30 days, n = 62 with 1 drop-out.
ParticipantsCanada, adults, 18 to 62 years, good general and oral health, 26 M: 36 F.
InterventionsColgate Actibrush versus Colgate diamond headed manual for 1 min twice daily. Use of timer not stated.
OutcomesNavy (Rustogi) plaque index, Löe and Silness (Chilton) gingival index, full mouth at 30 days, no adverse effects.
NotesManufacturer funded. No pre-examination brushing for 8 hours.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "randomly assigned..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information.
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 1/62. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Sharma 2010

MethodsRCT, parallel, single blind, 4 weeks, n = 132 with 3 drop-outs.
ParticipantsUSA, adults, aged 18 to 56 years, ≥18 years old, good general health. Gingivitis 1.75-2.3.
InterventionsOral B Pulsonic versus ADA manual toothbrush, 2 min and twice daily.
OutcomesRustogi modified Navy plaque index, modified gingival index, full mouth at 0, 4 weeks. No reported adverse events from both groups.
NotesManufacturer funded. Pre-examination instruction: abstain from oral hygiene procedure 12 hours prior to investigation.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "...randomly allocated via a computer-generated balance and assignment program to one of the two toothbrush test groups...."
Allocation concealment (selection bias)Low riskQuote: "... test product distribution processes were conducted in a separate area not accessible to the clinical examiner and data recorders."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "examiner blind, parallel group design."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 3/132. Unlikely to influence resutls.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Silverman 2004

MethodsRCT, parallel, single blind, 6 weeks, n = 59 with 2 drop-outs.
ParticipantsUSA, children, 4 to 5 years, excluded: history of periodontal disease.
InterventionsOralgiene 60 second time machine versus Oral B Mickey Mouse versus Oral B Rugrats 20; (2 powered and 1 manual), 60 seconds twice daily for Oralgiene, others 2 min twice daily. Own toothpaste used. Timer used.
OutcomesTuresky modified Quigley and Hein plaque indices and Löe and Sillness gingival indices at 0, 6 weeks. Whole mouth. No adverse effects reported. Mechanical reliability checked on compressive load needed to activate the powered toothbrush, revealed higher compressive load needed for Oralgiene 60 seconds.
Notes

Manufacturer funded. Use own toothpaste. Less parents involvement. All examination done at school.

Baseline, pre-brushing and post-brushing data available but decided to use the baseline data. The Oral B Rugrats 20 (manual) and Oral B MIckey mouse (powered) are considered for analysis.

Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "Using random numbers table..."
Allocation concealment (selection bias)Low riskQuote: "..the assignment of toothbrushes and brushing were performed without the presence of examining investigator.."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskReported as blind.
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 2/59. Reasons unclear, but unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases. Age of children?

Singh unpublished

MethodsRCT, parallel, single blind, 60 days, n = 73 with 8 drop-outs.
ParticipantsUSA, orthodontic patients, 11 to 19 years, >19 teeth, good health, no prophylaxis within last month.
InterventionsPulse Plaque Remover versus Oral B 35, 2 min. Frequency not stated. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) plaque index, papillary bleeding score (Loesche) for gingivitis.
NotesManufacturer funded. No pre-examination brushing for 12 to 24 hours.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "The examiner were blinded with respects to the methods used for brushing.."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs: 8/73. Unclear as to which group drop-outs came from.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Soparkar 1964

MethodsRCT, parallel, single blind, 11 weeks, n = 270 with 32 drop-outs.
ParticipantsUSA, college students non-dental.
InterventionsUnknown action powered versus old manual with normal regimen. Use of timer not stated.
OutcomesGingival index (assumed Löe and Silness) on 0-3 scale at 11 weeks. Anterior teeth only.
NotesNo pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...divided at random..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskQuote: "..the examiner was not aware of either the previous gingival score of the subject being examined or the type of toothbrush...."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs: 32/270. Reasons for drop-outs not discussed; unclear as to which group drop-outs came from.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Soparkar 2000

MethodsRCT, parallel, single blind, 30 days, n = 66 with 3 drop-outs.
ParticipantsUSA, healthy adults, 18 to 70 years, 25 M: 38 F (data on drop-outs not presented).
InterventionsColgate Actibrush versus ADA approved manual brush, 1 min twice daily. Use of timer not stated.
OutcomesRustogi modification of Navy plaque index and Mandel-Chilton modification of Löe Silness gingival index, all surfaces.
NotesManufacturer funded. No pre-examination brushing for 8 hours.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "It was a parallel, examiner-blind, randomised, balanced, two-group design..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "It was a parallel, examiner-blind, randomised, balanced, two-group design..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 3/66 completed. 3 from ADA group failed to complete. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Sowinski 2000

MethodsRCT, parallel, single blind, 30 days, n = 110 with no drop-outs.
ParticipantsUSA, adults, 18 to 70 years, >15 teeth, no orthodontic appliances, no oral disease, 22 M: 88 F.
InterventionsColgate Actibrush versus Colgate diamond head manual, 1 min twice daily. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) and Löe and Silness gingival index, full mouth at 30 days. No adverse events.
NotesManufacturer funded. No pre-examination brushing for 24 hours.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

ADA guidelines followed but no word random. Only mentions that "Qualifying participants were stratified into two balanced treatment groups according to their baseline plaque index and gingivitis index scores."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "This independent clinical study, employed an examiner-blind, two-treatment...."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Stabholz 1996

MethodsRCT, parallel, single blinded, n = 56 with 4 drop-outs, 60 days.
ParticipantsIsrael, general population, no medical conditions.
InterventionsPlaq and White A to Z technology versus Oral B 35 as per normal regimen. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) and Löe and Silness gingival and Eastman bleeding on probing indices on Ramfjord teeth at 15 and 30 days. No difference in soft tissue trauma between brush types.
NotesParticipants asked to refrain from brushing for 12 hours prior to each assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned..."

Insufficient information.

Allocation concealment (selection bias)Unclear risk

Quote: "An independent person was responsible for distributing the different toothbrushing and was the only..."

Insufficient information given lack of detail regarding randomisation.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Each examiner recorded 28 participants of both groups without knowing their brush assignment.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 4/56. 2 participants from each group did not complete for reasons not related to the protocol.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Stoltze 1994

MethodsRCT, parallel, unclear blinding method used, n = 40 with 2 drop-outs, 6 weeks.
ParticipantsDenmark, young adults 18 to 30 years, with plaque and gingival scores >1, >20 teeth, no medical problems.
InterventionsBraun Oral B Plak Control D5 versus Tandex 40 manual, 2 min twice daily. Use of timer not stated.
OutcomesSilness and Löe plaque index, Löe and Silness gingival index at all sites, 1, 2 and 6 weeks. Whole mouth recording PI and GI. No gingival abrasion reported.
NotesNo pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...participants were at random allocated to a group..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information.
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 2/40. Reasons not stated. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Terezhalmy 1995a

MethodsRCT, parallel, single blind, 6 months, n = 54 with 4 drop-outs.
ParticipantsUSA, adults, good health and free of oral pathology.
InterventionsUltra-sonex ultrasonic versus Oral B manual 3 min twice daily. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) plaque index and Löe and Silness gingival index at all sites and Eastman bleeding on probing index on contralateral Ramjford teeth. Assessed at 15 and 30 days and 6 months. No soft tissue trauma.
NotesParticipants asked to refrain from brushing 12 to 14 hours prior to assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information.
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 4/54. Reasons for drop-outs was breach of compliance. Unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Toto 1966

MethodsRCT, parallel, blinding unclear, 120 days, n = 527 with 17 drop-outs.
ParticipantsUSA, boarding school children, 6 to 18 years.
InterventionsSunbeam cordless versus unspecified manual. Frequency not stated. Use of timer not stated.
OutcomesPMA index, whole mouth.
NotesFunding not clear. No pre-examination instructions.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...distributed at random..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskInsufficient information.
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 17/527. Reasons not discussed but unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Tritten 1996

MethodsRCT, parallel, single blind, 12 weeks, n = 60 with 4 drop-outs.
ParticipantsUSA, adults 18 to 65 years, dental hospital patients, no professional cleaning previous 3 months, minimum 20 teeth, no previous periodontal treatment and unaware of active pregnancy.
InterventionsSonicare versus Butler 311, 2 min twice daily. Timer supplied.
OutcomesQuigley and Hein (Turesky) plaque index all teeth, Löe and Silness gingival index Ramfjord teeth. Gingival abrasion seen in 5 manual and 1 powered brush subjects.
NotesManufacturer funded.
Pre-brushing evaluation.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "..patients were randomised by having them draw their group assignment from a box containing a mixture of 30 labels marked 'manual group' and 30 labels marked ..."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "One investigator (CT), who was blinded to the brush assignments of each group.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 4/60. Excluded from analysis; either received antibiotics therapy (2) or failed to appear for 1 of the scheduled study visit (2). Drop-outs unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

van der Weijden 1994

MethodsRCT, parallel, single blind, 8 months, n = 87 with 10 drop-outs.
ParticipantsNetherlands, non-dental students, bleeding on probing at least 35% of sites and modified gingival index of at least 1, no previous experience of electric toothbrush. Healthy. No ortho. No pockets >5 mm.
InterventionsBraun Plak control versus Butler Gum 311 for 2 min. Timer supplied.
OutcomesSilness and Löe plaque index, Lobene gingival index at all sites at 1, 2, 5, 8 months. Whole mouth recording PI and GI. 12 manual brush subjects and 5 powered brush subjects with gingival abrasion. Calculus scored no difference in change between groups.
NotesParticipants asked to brush thoroughly, but not within 1 hour of assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly divided..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Therefore in the course of the experiment, the examiner was unaware of the brush types used by the subject.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 10/87. 8 particpants (control group) and 2 particpants (powered brush) left the study because of scheduling conflicts with clinical examination.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Van Swol 1996

MethodsRCT, parallel, double blind, 6 months, n = 71 with 7 drop-outs.
ParticipantsUSA, adults, >20 teeth, not using mouthrinse, 9 M: 55 F.
InterventionsHyG ionic brush (active) versus HyG ionic brush (non-active), usual time twice daily. Use of timer not stated.
OutcomesQuigley and Hein plaque index and Löe and Silness gingival index, whole mouth at 3 and 6 months. Adverse events not reported despite being collected.
NotesManufacturer funded. No pre-examination instructions.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "The subject were given prepackaged and coded hyG ionic action toothbrush. The toothbrushes were received evenly divided (36 of each) between those that had active batteries .."
Allocation concealment (selection bias)Low riskQuote: "Each packet had a code number that was recorded for the subject at the time of delivery neither the researchers nor the subjects knew whether their toothbrush contained an active or inactive battery."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "Neither the researcher nor the subject knew wether their toothbrush contained an active or inactive battery."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs: 7/71. Reasons were "four did not use their assigned toothbrush exclusively during the test period, and three took physician prescribed antibiotics." Number of drop-outs by group unlcear but unlikely to influence results.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Walsh 1989

MethodsRCT, parallel, single blind, n = 108, 6 months, drop-outs unclear.
ParticipantsUSA, adults from university and dental clinics, 18 to 65 years, >20 teeth, no dental/medical problems, gingival index >1 on 6+ sites of 18 sites probed on Ramfjord teeth.
InterventionsLPA/Broxo powered versus Oral B 40 manual, twice daily. Use of timer not stated.
OutcomesSilness and Löe plaque index on Ramfjord teeth, bleeding on probing on Ramfjord teeth at 3, 6 months. No soft tissue changes reported. Stain reported as no difference between brush types.
NotesNo pre-examination instructions reported.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskQuote: "...subjects were randomly allocated to groups in consecutive order by time and date of entry into study."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "examiners did not known to which groups the patients belonged....."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskInsufficient information to determine drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Warren 2001

MethodsRCT, parallel, single blind, 12 weeks, n = 110 with 9 drop-outs.
ParticipantsUSA, adult volunteers, 18 to 65 years, >18 teeth, plaque index >1.8, non-smokers, with no medical problems.
InterventionsBraun Oral B D 17 versus ADA standard manual, 2 min twice daily. Timer supplied.
OutcomesQuigley and Hein (Turesky) plaque index, Löe and Silness gingival index and modified Löe and Silness bleeding index, on all sites at 1, 3 months. Whole mouth recording PI and GI. No soft tissue changes reported.
NotesManufacturer funded.
Participants asked to refrain from brushing 12 to 18 hours prior to assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskQuote: "...were randomly assigned to one of two treatment groups, according to the method of Zelen."
Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..all subjects were evaluated by the same examiner who was unaware of the types of toothbrush..."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 9/110. Reasons unrelated to intervention and drop-outs evenly balanced.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Wilson 1993

MethodsRCT, parallel, single blind, 12 months, n = 32 with 3 drop-outs.
ParticipantsUSA, adults, 18+ years, minimum 20 teeth, at least 50% tooth surface plaque coverage (O'Leary), bleeding score >0.75. Barnett-Muhleman bleeding index, no medical problems, no orthodontics, no untreated perio or pockets >6 mm.
InterventionsInterplak, Bausch and Lomb versus Butler 311, 3 min. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) plaque index, Barnett Muhleman gingival index on all sites at 1, 2, 6, 9 and 12 months. Whole mouth recording PI and GI. No difference in gingival abrasion found between brush types.
NotesParticipants asked to brush 1 hour prior to assessment.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..a single-blind, ....."
Incomplete outcome data (attrition bias)
All outcomes
High riskDrop-outs: 3/32. All drop-outs from control group. Reasons were: 1 generalised periodontal diseases progression; 2 non-compliance/withdrawn from study.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Yankell 1996

MethodsRCT, parallel, single blind, 4 weeks, n = 66 with 1 drop-out.
ParticipantsUSA, children with 4 of 6 Ramfjord teeth present, no medical problems.
InterventionsRowenta Dentiphant versus Oral B 20, 1 min twice daily. Use of timer not stated.
OutcomesQuigley and Hein (Turesky) plaque and Löe and Silness (Lobene) gingival indices on Ramjford teeth at 2 and 4 weeks. No soft tissue changes reported.
NotesManufacturer funded.
Pre-brushing evaluation.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned.."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "The same clinical investigators saw and assessed the same subjects at each examination period and were unaware of the toothbrush product being used by the subjects."
Incomplete outcome data (attrition bias)
All outcomes
Unclear risk

Quote: "...attrition not related to product use.."

Insufficient information.

Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Yankell 1997

MethodsRCT, parallel, single blind, 30 days, n = 128 with 13 drop-outs.
ParticipantsUSA, adults, 18 to 50 years, >18 teeth, no current orthodontic bands, no medical problems.
InterventionsRowenta Plaque Dentacontrol Plus versus Sonicare versus Braun Oral B Ultra versus Oral B P35, 2 min twice daily. Timer specified for powered.
Excluded Rowenta data which were 5 min twice daily.
OutcomesQuigley and Hein (Turesky) plaque and Eastman bleeding indices on Ramfjord teeth and also Löe and Silness (Lobene) gingival index on whole mouth at 4 weeks. No soft tissue changes reported.
NotesRowenta data excluded due to extended brushing period.
Participants asked to refrain from brushing 10 to 16 hours before evaluation.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned..."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "..single-blind.."
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskDrop-outs: 13/128. Quote: "..attrition not related to product use.."
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Yukna 1993b

MethodsRCT, parallel, single blind, 6 months, n = 42 with 2 drop-outs.
ParticipantsUSA, adults with past periodontal surgical treatment. Excluded if on antibiotics/NSAIDS or orthodontic appliances.
InterventionsInterplak, Bausch and Lomb versus unspecified manual brush. Use of timer not stated.
OutcomesQuigley and Hein and O'Leary plaque indices, Lobene gingival index and bleeding on probing. Whole mouth recording PI and GI. 4 of 20 powered brushes had mechanical failure.
NotesManufacturer funded.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned.."

Insufficient information.

Allocation concealment (selection bias)Unclear riskQuote: "All the instruction and device distribution were performed by auxiliary personal without examiner being present."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All intraoral examinations for a given patient were performed by one of the two examiners, who were blinded to the grouping of the subjects."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 2/42. Reasons for drop-outs were non-compliance with appointments (manual brush) and restorative dentistry resulted in too few scorable teeth (powered brush).
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasUnclear riskComparibility of groups at baseline unclear.

Zimmer 2002

MethodsRCT, parallel, single blind, 8 weeks, n = 64 with 1 drop-out.
ParticipantsGermany, adults, 18 to 56 years good general health, no periodontal disease, 32 M: 32 F.
InterventionsUltra Sonex Ultima versus Aronal compact manual, 3 min twice daily. Timer supplied.
OutcomesQuigley and Hein (Turesky) and papillary bleeding index, full mouth at 4 and 8 weeks.
NotesManufacturer funded.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned.."

Insufficient information.

Allocation concealment (selection bias)Low riskQuote: "..each participant received the assigned toothbrush and instructions for use by a person not involved in the study."
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote: "All examinations were treatment blind and performed by one examiner."
Incomplete outcome data (attrition bias)
All outcomes
Low riskDrop-outs: 1/64.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Zimmer 2005

  1. a

    ADA = American Dental Association; BOMP = bleeding on marginal probing; CAL= clinical attachment level; F = female; GI = gingival index; M = male; PAL = probing attachment level; PD = pocket depth; PI = plaque index; PMA = papillary marginal attachment; PPD = periodontal pocket depth; RCT = randomised controlled trial.

MethodsRCT, parallel, single blind, 8 weeks, n = 120, no drop-outs.
ParticipantsGermany, adults, 18 to 65 years, exclusion: orthodontic fixed appliance patient, severe periodontal disease, long-term use of NSAIDs, wear removable partial denture, less than 20 teeth, regular use of electric toothbrush, dental professionals.
Interventions2 electric toothbrushes: Cybersonic and Oral B 3D excel versus Elmex Super 29 manual, 2 min twice daily. Digital timer supplied.
OutcomesQuigley and Hein (Turesky) and papillary bleeding index, full mouth at 4 and 8 weeks. Nor report on adverse events.
NotesPeer review grant and other source of funding. Pre-intervention scaling ad prophylaxis.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk

Quote: "...randomly assigned.."

Insufficient information.

Allocation concealment (selection bias)Unclear riskInsufficient information.
Blinding of outcome assessment (detection bias)
All outcomes
Low riskQuote "All examination were treatment blind.."
Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs.
Selective reporting (reporting bias)Low riskAdequate reporting of important outcomes.
Other biasLow riskNo other apparent biases.

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Aass 2000Less than 28 days.
Ainamo 1991Contacted authors for more information, no reply after 3 months.
Albers 1988Less than 28 days.
Anaise 1976Less than 28 days.
Andreana 1998No movement of powered head.
Arceneaux 1996Less than 28 days.
Ash 1967Contacted authors for more information, no reply after 3 months.
Barnes 2003Less than 28 days.
Bartizek 2002Less than 28 days.
Bhanji 2002Outcome not under consideration.
Biesbrock 2005Potential high for compromised self toothbrushing efficacy.
Blahut 1993Brush used by another person.
Buchmann 1987Less than 28 days.
Chaikin 1965Less than 28 days.
Chilton 1962Split-mouth study.
Ciancio 1990Less than 28 days.
Ciancio 1998Contacted authors for more information, no reply after 3 months.
Cohen 1964Potential high for compromised self toothbrushing efficacy.
Conforti 2003Less than 28 days.
Conroy 1965Less than 28 days.
Conroy 1966Less than 28 days.
Coontz 1983Less than 28 days.
Coontz 1985Less than 28 days.
Cronin 1996aCombined intervention.
Cronin 2000Less than 28 days.
Cronin 2001Data on number of participants in each group not presented. The study will be included once these data are determined.
Cross 1962bLess than 28 days.
Danser 2000Less than 28 days.
Danser 2003Split-mouth design.
de Leeuw 1977Abstract only.
Dentino 1999Outcomes not under consideration.
Derbyshire 1964Less than 28 days.
Dogan 2004Less than 28 days.
Doherty 1999Less than 28 days.
Doll 1999Less than 28 days.
Dorfer 2001Less than 28 days.
Dorfer 2001aSplit-mouth design.
Dunkin 1975Less than 28 days.
Elliott 1963Less than 28 days.
Farrell 2006Potential high for compromised self toothbrushing efficacy.
Fourel 1974Split-mouth design.
Fraleigh 1965Split-mouth design.
Galustian 2002Less than 28 days.
Goldman 1975Less than 28 days.
Grossman 1994Less than 28 days.
Hall 1971Potential high for compromised self toothbrushing efficacy.
Heasman 2001Less than 28 days.
Heins 2002Less than 28 days.
Heintze 1996Combined intervention.
Hoover 1962Less than 28 days.
Hotta 1992Less than 28 days.
Hou 2002Single used study design.
Howorko 1993Less than 28 days.
Johnson 1994aAbstract with insufficient information.
Jongenelis 1997Less than 28 days.
Killoy 1988Previously author was contacted for information but no reply after 3 months.
Killoy 1989Contacted authors for more information, no reply after 3 months.
Killoy 1993Contacted authors for more information, no reply after 3 months.
Lamendola-Sitenga 1998No mechanical action of brush head.
Lange 1978Less than 28 days.
Leftkowitz 1962Less than 28 days.
Lim 1995Contacted authors for more information, no reply after 3 months.
Long 1985Split-mouth design.
Love 1988Contacted authors for more information, no reply after 3 months.
Lundergan 1988Less than 28 days.
Mantokoudis 2001Less than 28 days.
Mascarenhas 2005Less than 28 days.
Mayer 1978Less than 28 days.
Mayer 1988Split-mouth design.
McAllan 1976Not true randomisation; alternate allocation.
Moritis 2002Less than 28 days.
Morris 1997Contacted authors for more information, no reply after 3 months.
Moschen 1999Less than 28 days.
Mueller 1987Contacted authors for more information, after reply still not adequate to be included.
Murray 1989Outcomes not under consideration.
Niemi 1986Less than 28 days.
Niemi 1987Less than 28 days.
Niemi 1988Split-mouth design.
Ojima 2003Less than 28 days.
Ousehal 2011Participants selected from population at random, but not allocated to groups at random.
Owen 1972Cross-over study, contacted authors for more information, no reply after 3 months.
Palmer 1999Contacted authors for more information, no reply after 3 months.
Parizi 2011Less than 28 days.
Pelka 2008Split-mouth design.
Pizzo 2010Single used study design.
Platt 2002Less than 28 days.
Powers 1967Less than 28 days.
Preber 1991Less than 28 days.
Quigley 1962Less than 28 days.
Quirynen 1994Split-mouth design.
Rashid 1998Less than 28 days.
Renton-Harper 2001Less than 28 days.
Roscher 2004Less than 28 days.
Ruhlman 2001Less than 28 days.
Ruhlman 2002Less than 28 days.
Sato 1995Less than 28 days.
Schifter 1983Less than 28 days.
Schmage 1999Split-mouth design.
Schuler 1996Abstract only.
Sharma 2001aSplit-mouth design.
Sharma 2005Potential high for compromised self toothbrushing efficacy.
Sharma 2006Potential high for compromised self toothbrushing efficacy.
Sharma 2011Potential high for compromised self toothbrushing efficacy.
Silverstone 1992Contacted authors for more information, no reply after 3 months.
Singh 2005Potential high for compromised self toothbrushing efficacy.
Smith 1964Cross-over study, contacted authors for more information, no reply after 3 months.
Stadtler 1984Less than 28 days.
Swenson 1967Contacted authors for more information, no reply after 3 months.
Taylor 1995Less than 28 days.
Tenenbaum 1984Less than 28 days.
Terezhalmy 2005Less than 28 days.
Thienpont 2001Cross-over study, contacted authors for more information, no reply after 3 months.
Trimpeneers 1997Cross-over study, contacted authors for more information, no reply after 3 months.
Trombeli 1995Less than 28 days.
Tscharre-Z 1989Combined interventions.
van der Weijden 1993Less than 28 days.
van der Weijden 1998Split-mouth study.
van der Weijden 2002aSplit-mouth study.
van Venrooy 1985Less than 28 days.
Vandana 2004Potential for compromised self toothbrushing efficacy.
Versteeg 2006Teeth brushed by other person.
Vervliet 1989Split-mouth design.
Walsh 1984Less than 28 days.
Warren 2007Less than 28 days.
Whitmyer 1998Potential high for compromised self toothbrushing efficacy.
Wiedemann 2001Split-mouth design.
Wilcoxon 1991Cross-over study, contacted authors for more information, no reply after 3 months.
Williams 2003aLess than 28 days.
Williams 2004Less than 28 days.
Williams 2010No movement of brush head.
Wilson 1991Contacted authors for more information, no reply after 3 months.
Yankell 1994Less than 28 days.
Yukna 1993aCombined intervention.
Zimmer 1999Less than 28 days.

Characteristics of studies awaiting assessment [ordered by study ID]

Borutta 2002

Methods 
Participants 
Interventions 
Outcomes 
NotesUnable to locate a copy to date.

De Beule 1990

Methods 
Participants 
Interventions 
Outcomes 
NotesUnable to locate a copy to date.

Horton 1989

Methods 
Participants 
Interventions 
Outcomes 
NotesUnable to locate a copy to date.

Jain 2013

Methods6-week, parallel arm RCT.
Participants

Adults (aged 18-28) with moderate gingivitis (at least 25% of test sites showing bleeding on probing).

Excludes orthodontic patients.

Interventions

Group 1 – Oral B Classic Ultraclean medium manual toothbrush.

Group 2 – Oral B Vitality Dual Clean powered toothbrush (rotation oscillation).

Both groups' intervention was combined with commercially available fluoridated toothpaste (Pepsodent Regular).

Outcomes

Gingivitis (Löe and Silness gingival index, 1963) recorded at 1, 2, and 6 weeks.
Plaque (O'Leary plaque index, 1972) recorded at 1, 2, and 6 weeks.

Oral hygiene (Green and Vemillion Oral Hygiene Index Simplified (OHI-S), 1964) recorded at 1, 2, and 6 weeks.

Notes 

Marini 2014

Methods20-week, 4-parallel arm RCT.
ParticipantsAdolescent fixed-orthodontic treatment patients.
Interventions

Group 1 – Oral B Triumph 5000 powered toothbrush (rotation oscillation), combined with oral hygiene instruction and motivation at baseline and at 4, 8, 12, 16, and 20 weeks.

Group 2 – Oral B Triumph 5000 powered toothbrush (rotation oscillation), combined with oral hygiene instruction and motivation at baseline.

Group 3 – Oral B Ortho P35, combined with oral hygiene instruction and motivation at baseline and at 4, 8, 12, 16, and 20 weeks.

Group 4 – Oral B Ortho P35, combined with oral hygiene instruction and motivation at baseline.

All groups' intervention was combined with commercially available fluoridated toothpaste (Colgate Total, 1450 ppm fluoride).

All groups also received an interdental brush (Plakkontrol, 7 mm) at baseline and at 8 and 16 weeks.

Replacement brushes (both manual and powered groups) were also issued at 8 and 16 weeks.

OutcomesPlaque index (Quigley Hein plaque index, 1962) recorded at baseline and at 4, 8, 12, 16, and 20 weeks.
Notes 

Mayer 1990

Methods16-week, parallel arm RCT.
ParticipantsAdults (aged 20-30) with poor oral hygiene (scoring between 76-90 on approximal area plaque index).
Interventions

Group 1 – Oral B Plus 30 manual toothbrush.

Group 2 – Braun dental timer D31 electric toothbrush.

Both groups' intervention was combined with commercially available toothpaste (Oral-B Zendium).

OutcomesPlaque (Lange approximal area plaque index, 1987), recorded at 1, 2, 3, 4, 9, 10, and 11 weeks.
Notes 

Nathoo 2012

Methods12-week, parallel arm RCT.
Participants

Adults (aged 18-70) with mild gingivitis (at least scoring 1 on Löe and Silness gingival index) and mild plaque (at least scoring 0.6 on Rustogi modification of the modified Navy plaque index).

Excludes orthodontic patients.

Interventions

Group 1 – Colgate ProClinical A1500 powered toothbrush with Triple Clean Brush Head (auto mode).

Group 2 – Oral B Indicator manual flat-trim toothbrush.

Both groups' intervention was combined with commercially available fluoridated toothpaste (Colgate Cavity Protection).

Outcomes

Gingivitis (Löe and Silness gingival index, 1963), recorded at baseline and at 4 and 12 weeks.

Gingival bleeding (gingivitis severity index, 1990), recorded at baseline and at 4 and 12 weeks.

Plaque (Rustogi modification of the modified Navy plaque index, 1992), recorded at baseline and at 4 and 12 weeks.

NotesStudy supported by Colgate-Palmolive.

Sharma 2001

Methods30-day, parallel arm RCT.
ParticipantsHealthy adults.
Interventions

Group 1 – Colgate Actibrush battery-powered toothbrush.

Group 2 – Colgate Plus Diamond Head, full-head soft-bristled manual toothbrush.

Both groups' intervention was combined with commercially available toothpaste (type not mentioned).

Outcomes

Plaque (index not mentioned), reported at baseline and 30 days.

Ginigivitis (index not mentioned), reported at baseline and 30 days.

NotesAbstract only.

Sharma 2012

Methods4-week, parallel arm RCT.
Participants

Adults with mild-moderate gingivitis.

Excludes orthodontic patients.

Interventions

Group 1 – Oral B Professional Deep Clean TRICLEAN 1000 multi-directional power toothbrush (D16u/EB30) (AKA Oral-B TriZone).

Group 2 – ADA reference standard soft manual control toothbrush.

Both groups' intervention was combined with commercially available fluoridated toothpaste (Crest Cavity Protection, 0.243% sodium fluoride).

Outcomes

Gingivitis (Lobene modified gingival index), reported at baseline and 4 weeks.

Gingival bleeding (gingival bleeding index), reported at baseline and 4 weeks.

Plaque (Rustogi modified Navy plaque index), reported at baseline, and 1 and 4 weeks.

Notes 

Swierkot 2013

  1. a

    ADA = American Dental Association; ppm = parts per million; RCT = randomised controlled trial.

Methods52-week, parallel arm RCT.
ParticipantsPartially edentulous adults (aged 45-78), with at least 1 posterior implant.
Interventions

Group 1 – Philips Sonicare FlexCare sonic toothbrush.

Group 2 – Oral B P40 manual toothbrush.

Both groups' intervention was combined with commercially available fluoridated toothpaste (Colgate Total).

Outcomes

Gingivitis (Löe and Silness gingival index, 1963; bleeding on probing scale), recorded at baseline and at 3, 6, 9 and 12 months (for both tooth and implant).

Plaque (Silness and Löe plaque index, 1964), recorded at baseline and at 3, 6, 9 and 12 months (for both tooth and implant).

NotesStudy supported by Philips Healthcare Systems.

Ancillary