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Comparative study of electric and manual toothbrushes in patients with fixed orthodontic appliances
ORIGINAL ARTICLE
Comparative study of electric and manual toothbrushes in patients with fixed orthodontic appliances Peter Heasman, MDS, FDS, RCPS, DRD, RCS, PhD,a Zoe Wilson, EDH,a Ian Macgregor, BDS, PhD, FDS, RCS,a and Peter Kelly, PhDb Newcastle upon Tyne and Middlesbrough, U.K. The objective of this three treatment, three period, single blind, cross-over trial was to evaluate the efficacy of three toothbrushes in a cohort of children undergoing fixed appliance orthodontic therapy. The brushes used were: (1) Dental Logic HP550 with regular brush head HP5924 (Philips, U.K.); (2) Braun Oral B Plaque Remover (D7) with dedicated orthodontic brush head OD5-1 (Braun AG, Germany); and (3) a manual dedicated orthodontic toothbrush (P35, Oral B Laboratories, Calif.). Sixty orthodontic patients, aged 10 to 16 years and wearing upper and lower fixed appliances, were screened and recruited with parental consent. After an oral soft tissue examination at baseline, the percentage of plaque-covered tooth surfaces and gingival bleeding sites were recorded using visible plaque and gingival bleeding indexes. Each subject was randomly allocated to one of three groups (n 5 20) with brushing sequences 1-2-3, 2-1-3, 3-2-1. The first brush was given 2 weeks after baseline (visit 1). The time interval for using each brush was 4 weeks at the end of which visible plaque and gingival bleeding indexes were recorded and a further prophylaxis given. Statistical analysis was undertaken with analysis of variance. Data were analyzed on a site-specific basis; buccal smooth and interproximal surfaces, lingual smooth and interproximal surfaces. At baseline the mean visible plaque index for all subjects were; buccal smooth, 52.5% (6 22.5%); buccal interproximal, 70.5% (6 18.5%); lingual smooth, 68.5% (6 21%); lingual interproximal, 76% (6 16%). At visit 1, the plaque scores at all surfaces had reduced significantly compared to baseline, but there had been no active treatment. This was attributed to a Hawthorne effect. Subsequently, there were no significant effects on visible plaque (or gingival bleeding) indexes with any toothbrush at any tooth surfaces. This suggests that the new HP550 is equally effective as specifically designed orthodontic toothbrushes in removing plaque from patients with fixed orthodontic appliances. (Am J Orthod Dentofacial Orthop 1998;114:45-49.)
T
he regular and effective removal of plaque from all surfaces of teeth, both above and below the gingival margin, is essential for the prevention of gingival and periodontal disease.1-3 Effective removal of plaque is compromised significantly when fixed orthodontic appliances are worn and the accumulation of plaque, and the development of gingivitis and gingival overgrowth are well-recognized problems.4-10 In some cases, a simple gingivitis may progress to destructive periodontitis although this does not appear to be a significant problem during orthodontic therapy in adolescents.11-15 In an attempt to facilitate plaque control in orthodontic patients, specifically designed manual and electric toothbrushes have been developed. From the Dental School at the University of Newcastle upon Tyne and the School of Health Science, University of Teesside. a Dental School, University of Newcastle upon Tyne. b School of Health Science, University of Teesside. Reprint requests to: Dr. P.A. Heasman, Restorative Dentistry, Dental School, Framlington Place, Newcastle upon Tyne, NE2 4BW, U.K. Copyright © 1998 by the American Association of Orthodontists. 0889-5406/98/$5.00 1 0 8/1/84774
Manual brushes with V-shaped longitudinal grooves in the brushing surface are intended to improve brushing around brackets and arch wires, although their effectiveness in reducing gingivitis compared with conventional brushes is questionable.16 Electric toothbrushes can improve plaque control without causing damage to the components of the orthodontic appliance. For example, rotary and counterrotational brushes have been shown to be particularly effective in plaque removal and reducing gingivitis in orthodontic patients.17-21 Improvements in the design of electric toothbrushes are constantly being sought and one recently marketed product, the Dental Logic HP550 (Philips DAP, Groningen, Netherlands), has incorporated several practical features that may be of value in improving plaque control around fixed appliances. These features include brush head movements in two directions and at two speeds simultaneously, and a unique, soft pressure gum protection system that regulates the amount of force (maximum 300 gm) that is applied to the teeth and gingiva. The brush (or brushhead) was 45
46 Heasman et al.
not, however, designed specifically for use by orthodontic patients. The aim of this study was to evaluate the efficacy of the HP550 Dental Logic brush, a manual orthodontic toothbrush, and a powered orthodontic toothbrush in decreasing plaque accumulation and gingival inflammation in a cohort of children undergoing orthodontic treatment. MATERIAL AND METHODS This is a three-period, three-treatment, balanced, Latin square-type, single-blind cross-over clinical trial of three toothbrushes with children undergoing fixed orthodontic treatment. Ethical approval for the protocol was granted by the Joint Ethics Committee of the Newcastle and North Tyneside Health Authorities. Sixty patients (males and females) between the ages of 10 and 16 years were recruited from the Department of Orthodontics at Newcastle Dental Hospital. All patients had started orthodontic treatment within the previous 12 months and had at least 12 brackets (or bands) on teeth in each arch. Written informed consent was given by the parent or legal guardian. Patients were excluded if they had 1. previously used an electric toothbrush or a manual orthodontic brush 2. a history of early onset periodontal disease, 3. a mental handicap, 4. a physical handicap that restricted free movement of hands or fingers 5. received oral hygiene instruction from a dental professional within the previous 6 months The patients were examined by a clinician (screening visit) for suitability and an information sheet was given to the parent or guardian. Enrollment for the baseline visit followed the provision of written consent. At baseline, 2 weeks after screening, each patient was allocated at random, to one of three groups (n 5 20) each with a sequenced three-period regimen of toothbrushing; each period of 4 weeks duration was associated with the use of one toothbrush. The trial toothbrushes were (1) Oral B manual orthodontic brush, (2) Braun electric toothbrush (D7, Braun AG, Germany) with orthodontic head OD5-1, (3) HP550 electric toothbrush with head HP5924. The sequence of treatments for each numerically balanced allocation of patients was 1-2-3, 2-1-3, 3-2-1. A standard, fluoride-containing dentifrice was given to all patients for use throughout the trial. Design At baseline an examination of the gingiva was undertaken for visible signs of abrasion, ulceration, swelling, or gingival recession. Plaque was scored with the Visible Plaque Index (VPI)22 at six sites around each tooth (mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual, distolingual). Gingival bleeding was scored at four
American Journal of Orthodontics and Dentofacial Orthopedics July 1998
sites around each tooth (mesial, buccal, lingual, distal) with the Gingival Bleeding Index (GBI).22 Bleeding was provoked by probing each site with a TPS (pressure sensitive) probe (Vivadent, Schaan, Leichtenstein). Patients were next seen (visit 1) 2 weeks after the baseline visit. Clinical scores and the oral examination were repeated. The fixed appliances were adjusted if required; to maintain the blind nature of the design and to prevent bias, instructions in the use of all three brushes were given (Z.W.). For the electric toothbrushes, the manufacturer’s instructions were read through with the patient; the purpose and design of the manual toothbrush were also discussed. A combination of the Bass and Charters techniques was taught diagrammatically with use of the manual toothbrush so that plaque was removed from the gingival sulcus and the gingival facing surface of brackets. The suggested brushing time for the electric toothbrushes was at least 3 minutes, twice daily. A minimum of 2 minutes brushing time (twice daily) was recommended for the manual toothbrush. The first brush in the sequence was then given to each patient and by a different researcher (P.H.) from the one who had given the instructions in toothbrushing. Appointment times for each visit were scheduled for between 2 and 3 hours after an episode of toothbrushing. At the conclusion of each 4-week brushing period, oral examination and clinical scores were repeated, and the orthodontic appliances adjusted where necessary. A dental prophylaxis given before the sequence was repeated for the second and third brushes. The clinical indexes were measured, and the instructions in using all three toothbrushes were repeated. On completion of the trial all patients continued with their orthodontic treatment. Repeatability Two research dental hygienists carried out the examinations and clinical scoring. A prestudy calibration (repeatability) exercise was undertaken scoring full mouth sites on each of five subjects (10 to 15 years old) who were not involved in the main study. The mean intraexaminer exact agreements for the examiners were VPI, 88% and 84%; GBI, 89% and 92%. The mean interexaminer exact agreements were VPI, 83%; GBI, 88%. Statistical analysis Statistical analysis was undertaken with analysis of variance with treatments for subject, period, and toothbrushing regimen. The VPI (primary outcome variable for toothbrush efficacy) was analyzed on a site-specific basis: buccal smooth (Bs) and interproximal (Bi) surfaces, lingual smooth (Ls) and interproximal (Li) surfaces. Good clinical practice The study conformed to guidelines for Good Clinical Practice. The study site and procedure were audited by an independent assessor on three occasions, and no breach of
Heasman et al. 47
American Journal of Orthodontics and Dentofacial Orthopedics Volume 114, No. 1
protocol occurred. The projected recruitment time for subjects into the trial was 3 months although the period was 6 months. This did not affect the outcome or completion of the study. Results
All subjects completed the study. The cohort comprised 21 males and 39 females with the mean age of 13.6 (6 1.2) years. Mean site specific plaque indexes and gingival indexes at baseline and visit 1 are shown in Table I. Plaque indexes at all sites at visit 1 were consistently and significantly lower than those at baseline (at p 5 0.05; t test). There were, however, no differences in bleeding scores between baseline and visit 1. Tables II and III show the VPI at smooth and interproximal sites respectively for the buccal and lingual tooth surfaces. Data are presented for each brush at the end of each brushing period (of 4 weeks), as well as for all brushes and for all periods. Table IV shows the full mouth gingival bleeding scores after the use of each brush at the end of each brushing period. The data for all brushes and all periods are also shown. In summary, there were no differences between the brushes in their efficacy in reducing plaque scores at buccal (smooth/interproximal) or lingual (smooth/interproximal) sites. Similarly, there were no differences between the brushes in their effect on gingival bleeding scores. There was no evidence of gingival trauma in any subject at any time during the study. DISCUSSION
The study was designed to test the plaque removing effects of a manual orthodontic toothbrush and two electric toothbrushes in a cohort of patients with fixed orthodontic appliances. The manual brush has a longitudinal groove in the brushing surface to facilitate brushing around brackets and arch wires. The Braun brush head OD5-1 is also designed to improve cleaning around fixed appliances and the brush moves with a rotating/oscillating motion. The brush head on the Philips HP550 moves simultaneously in two directions and at two speeds. This brush is not specifically recommended for patients with fixed orthodontic appliances but the brush head movements may be considered appropriate for cleaning the gingival crevice and interproximally, beneath components of an appliance. The Braun Plaque Control electric toothbrush (models D3, D5, and D7) has repeatedly been shown to remove more plaque than manual brushes in non-orthodontic patients in both cross-over and
Table I. Plaque scores (%) (mean 6 SD) at baseline and visit 1
VPI Buccal Smooth Interproximal Lingual Smooth Interproximal GBI
Baseline
Visit 1
Baseline—Visit 1
53 (623) 71 (619)
39 (620) 65 (618)
p , 0.001 p , 0.02
69 (621) 76 (616) 31 (619)
57 (621) 68 (618) 26 (616)
p , 0.01 p , 0.05 p . 0.05
VPI, Visible Plaque Index. GBI, Gingival Bleeding Index. SD, Standard deviation.
parallel studies.23-27 The more specific question regarding the value of electric brushes for orthodontic patients has received less attention, although a number of different designs have been tested and the brushes found to be efficacious when compared to manual brushes.17-21 Our cross-over design enabled each brush to be tested on each subject. This eliminated any potential for intersubject variation to result from different numbers of brackets or types of components in the appliance. The inclusion of three ‘groups’ with different sequences of brushing was designed to compensate for the absence of a ‘wash-out’ period. It was considered extremely unlikely, however, that the use of one brush would influence the use of any other because of the different techniques required for each toothbrush. One of the main variables in toothbrushing studies reported in the literature is the period of observation. A time interval of 4 weeks has been shown to be sufficient to observe meaningful changes in plaque and bleeding.28-30 Studies of longer duration are more likely to allow observations that reflect an individual’s long-term dental hygiene practices at home, but a more precise evaluation of the efficacy and potential of a toothbrush may be less apparent as the compliance of subjects becomes an additional variable. As the efficacy of the HP550 had, as far as we are aware, not been determined in controlled clinical studies, we opted for the shorter period of observation. Another variable between studies is the time spent brushing. We recommended that each subject use the manual brush for 2 minutes, twice a day. It has previously been shown that brushing for 2 minutes with an electric brush will reduce plaque scores by 75% to 88% depending on the brush design.31 As none of the subjects had previously used an electric toothbrush and in view of the potential difficulties in cleaning around fixed ortho-
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American Journal of Orthodontics and Dentofacial Orthopedics July 1998
Table II. Visible Plaque Index % scores (mean 6 SD) at smooth surfaces at the end of each experimental period Buccal
Manual brush Braun Electric OD5 Philips HP 550 All brushes
Lingual
Period 1
Period 2
Period 3
All periods
Period 1
Period 2
Period 3
All periods
39 (6 18) 39 (6 22) 39 (6 18) 39 (6 19)
— 42 (6 21) 32 (6 18) 38 (6 21)
28 (6 19) — 38 (6 20) 31 (6 32)
32 (6 19) 41 (6 21) 36 (6 20)
50 (6 24) 43 (6 26) 50 (6 20) 48 (6 24)
— 42 (6 22) 37 (6 18) 40 (6 21)
37 (6 19) — 48 (6 23) 41 (6 21)
42 (6 22) 43 (6 23) 45 (6 21)
SD, Standard deviation.
Table III. Visible Plaque Index % scores (mean 6 SD) at interproximal surfaces at the end of each experimental period Buccal
Manual brush Braun Electric OD5 Philips HP 550 All brushes
Lingual
Period 1
Period 2
Period 3
All periods
Period 1
Period 2
Period 3
All periods
61 (6 14) 61 (6 20) 64 (6 18) 62 (6 17)
— 59 (6 20) 63 (6 18) 60 (6 20)
59 (6 16) — 63 (6 13) 60 (6 15)
59 (6 16) 59 (6 20) 63 (6 16)
59 (6 22) 59 (6 17) 60 (6 21) 59 (6 19)
— 58 (6 22) 60 (6 14) 58 (6 19)
60 (6 16) — 62 (6 20) 61 (6 17)
60 (6 18) 58 (6 20) 60 (6 18)
SD, standard deviation.
Table IV. Full mouth Gingival Bleeding Index % scores (mean 6 SD) at the end of each experimental period
Manual brush Braun Electric OD5 Philips HP 550 All brushes
Period 1
Period 2
Period 3
All periods
21 (6 12) 20 (6 13)
— 16 (6 11)
14 (6 8) —
17 (6 10) 17 (6 12)
19 (6 12) 20 (6 12)
17 (6 10) 16 (6 11)
18 (6 9) 15 (6 9)
18 (6 10)
SD, Standard deviation.
dontic appliances, we increased the brushing time to 3 minutes when an electric brush was used. When designing the study, it was considered that the proximity of orthodontic bands and brackets to the gingival margin might complicate scoring of plaque. Plaque was therefore recorded dichotomously using the Visible Plaque Index rather than quantitatively, which is otherwise the preferred method in most longitudinal clinical trials. Plaque scores at all surfaces at baseline were greater than 50%, and our subjects therefore correspond to those considered to have ‘poor’ oral hygiene in the study of Heintze et al.21 This cross-over study of three electric and one manual brush found that over a 4 week period, the Braun Oral B and Rota-dent (Kusnacht, Switzerland) brushes were more efficacious in reducing full mouth plaque scores when compared with the Interplak (Bausch and Lomb, Germany) and a manual brush. When scores at specific surfaces were analyzed, however, none of the brushes demonstrated superiority.
The results of our study demonstrated equal efficacy in reducing plaque and gingival bleeding scores for the three products tested. No brush demonstrated superiority at either smooth or interproximal surfaces, although the plaque scores at smooth surfaces at baseline and thereafter were consistently lower compared with interproximal sites. The plaque scores for each brush at smooth and interproximal surfaces, regardless of the period and sequence of brushing, were consistently lower than those at baseline but virtually identical to those at visit 1. Indeed, the mean plaque scores at all surfaces at visit 1 were consistently and significantly lower than scores at baseline (p , 0.05; Table I). As none of the test brushes was used until visit 1 and no alteration in oral hygiene practices was recommended at baseline, the reduction in plaque scores observed between these visits is attributed to the Hawthorne effect.32 This change in behavior of subjects who anticipate involvement in a clinical trial has been observed previously and may be a source of variability for cross-over designs.33 We believe that this observation alone justifies the inclusion of the pretest period between screening and the first experimental period to allow a short period for Hawthorne stabilization. There was no significant difference between full mouth gingival bleeding scores at baseline and visit 1; this suggests that the reduction in plaque scores over the same period was clinically insignificant and insufficient to affect resolution of the inflammatory response. This apparent lack of correlation between
American Journal of Orthodontics and Dentofacial Orthopedics Volume 114, No. 1
plaque and gingivitis scores has also been observed by other workers.30,34 CONCLUSION This 4 week, cross-over study demonstrated that the Philips HP550, the dedicated electric Braun D7, and the manual (Oral B) orthodontic brushes were equally effective in removing plaque and reducing gingival inflammation as indicated by bleeding on probing in patients undergoing fixed orthodontic treatment. This suggests that further research is necessary to improve the designs of orthodontic toothbrushes. Clinicians and hygienists should appreciate that dedicated brushes may offer no advantages in cleaning interproximally and in the gingival crevice. REFERENCES 1. Suomi JD, Greene JC, Vermillion JR, Doyle JJ, Chang J, Leatherwood EC. The effect of controlled oral hygiene procedures on the progression of periodontal disease in adults: results after third and final year. J Periodontol 1971;42:152-60. 2. Nyman S, Rosling B, Lindhe J. Effect of professional tooth cleaning on healing after periodontal surgery. J Clin Periodontol 1975;2:80-6. 3. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. J Clin Periodontol 1981;8:239-48. 4. Baer PN, Coccaro PJ. Gingival enlargement coincident with orthodontic therapy. J Periodontol 1964;35:436-9. 5. Zachrisson BU, Zachrisson S. Caries incidence and orthodontic treatment with fixed appliances. Scand J Dent Res 1971;79:183-92. 6. Zachrisson BU, Zachrisson S. Caries incidence and oral hygiene during orthodontic treatment. Scand J Dent Res 1971;79:394-401. 7. Zachrisson S, Zachrisson BU. Gingival conditions associated with orthodontic treatment. Angle orthod 1972;42:26-34. 8. Shelley WB. Gingival hyperplasia from dental braces. Cutis 1981;28:149-50. 9. Legott PJ, Boyd RL, Quinn RS, Eakle WS, Chambers DW. Gingival disease pattern during fixed orthodontic treatment adolescents v adults. J Dent Res 1984;63:309. 10. Huser MC, Baehni PC, Lang R. Effects of orthodontic bands on microbiological and clinical parameters. Am J Orthod Dentofacial Orthop 1990;97:213-8. 11. Zachrisson BU, Alnaes L. Orthodontic conditions in orthodontically treated and untreated children. I. loss of attachment, gingival pocket depth and clinical crown height. Angle Orthod 1973;43:402-11. 12. Alstad S, Zachrisson BU. Longitudinal study of periodontal condition associated with orthodontic treatment in adolescents. Am J Orthod 1979;76:277-86. 13. Trossello VK, Gianelly AA. Orthodontic treatment and periodontal status. J Periodontol 1979;50:665-71. 14. Sadowsky C, BeGole EA. Long-term effects of orthodontic treatment on periodontal health. Am J Orthod 1981;80:156-70.
Heasman et al. 49 15. Hamp S-E, Lundstrom F, Nyman S. Periodontal conditions in adolescents subjected to multiband orthodontic treatment with controlled oral hygiene. Eur J Orthod 1982;4:77-86. 16. Williams P, Fenwick AM, Schou L, Adams SW. A clinical trial of an orthodontic toothbrush. Eur J Orthod 1987;9:295-304. 17. Long DE, Killoy WJ. Evaluation of the effectiveness of the Interplak home plaque removal instrument on plalque removal in orthodontic patients. Compend Contin Educ Dent 1985;6:s156-60. 18. Boyd RL, Murray P, Robertson PB. Effect of a rotary electric toothbrush versus manual toothbrush on periodontal status during orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:342-7. 19. Wilcoxen DB, Ackerman RJ, Killoy WJ, Love JW, Sakumura JS, Tira DE. The effectiveness of a counter rotational-action power toothbrush on plaque control in orthodontic patients. Am J Orthod Dentofacial Orthop 1991;99:7-14. 20. Trombeli L, Scabbia A, Griselli A, Zangari F, Calura G. Clinical evaluation of plaque removal by counterrotational electric toothbrush in orthodontic patients. Quintessence Int 1995;26:199-202. 21. Heintze SD, Jost-Brinkmann P-G, Loundos J. Effectiveness of three different types of electric toothbrushes compared with a manual technique in orthodontic patients. Am J Orthod Dentofacial Orthop 1996;110:630-8. 22. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35. 23. Van der Weijden GA, Danser MM, Nijboer A, Timmerman MF, Van der Velden U. The plaque-removing efficacy of an oscillating/rotating toothbrush: a short-term study. J Clin Periodontol 1993;20:273-8. 24. Van der Weijden GA, Timmerman MF, Nijboer A, Lie MA, Van der Velden U. A comparative study of electric toothbrushes for the effectiveness of plaque removal in relation to toothbrushing duration. J Clin Periodontol 1993;20:476-81. 25. Stoltze K, Bay L. Comparison of a manual and a new electric toothbrush for controlling plaque and gingivitis. J Clin Periodontol 1994;21:86-90. 26. Van der Weijden GA, Timmerman MF, Reijerse E, Snoek CM, Van der Velden U. Comparison of 2 electric toothbrushes in plaque-removing ability: professional and supervised brushing. J Clin Periodontol 1995;22:648-52. 27. Ainamo J, Hormia M, Kaunisatio K, Sorsa T, Suomalainen K. Effect of manual versus powered toothbrushes. J Dent Res 1991;70:557. 28. Yankell SL, Emling RC, Cohen DW, Vanarsdall RJ. A four-week evaluation of oral health in orthodontic patients using a new plaque-removal device. Compend Contin Educ Dent 1985;65:123-7. 29. Baab DA, Johnson RH. The effect of a new electric toothbrush on supragingival plaque and gingivitis. J Periodontol 1989;60:336-41. 30. Khocht A, Spindel L, Person P. A comparative study of the safety and efficacy of three toothbrushes. J Periodontol 1992;63:603-10. 31. Van der Weijden GA, Timmerman MF, Nijboer A, Lie MA, Van der Velden U. A comparative study of electric toothbrushes for the effectiveness of plaque removal in relation to toothbrushing duration. J Clin Periodontol 1993;20:476-81. 32. Roethlisberger FT, Dickson WJ. Management and the Worker. Harvard University Press 1939. 33. Robertson PB, Armitage GA, Buchanan SA, Taggart EJ. The design of trials to test the efficacy of plaque control agents for periodontal diseases in humans. J Dent Res 1989;68SpIss: 1667-71. 34. Spindel LM, Chauncey HH, Person P. Plaque reduction unaccompanied by gingivitis reduction. J Periodontol 1986;57:551-4.
Comparative study of electric and manual toothbrushes in patients with fixed orthodontic appliances Peter Heasman, MDS, FDS, RCPS, DRD, RCS, PhD,a Zoe Wilson, EDH,a Ian Macgregor, BDS, PhD, FDS, RCS,a and Peter Kelly, PhDb Newcastle upon Tyne and Middlesbrough, U.K. The objective of this three treatment, three period, single blind, cross-over trial was to evaluate the efficacy of three toothbrushes in a cohort of children undergoing fixed appliance orthodontic therapy. The brushes used were: (1) Dental Logic HP550 with regular brush head HP5924 (Philips, U.K.); (2) Braun Oral B Plaque Remover (D7) with dedicated orthodontic brush head OD5-1 (Braun AG, Germany); and (3) a manual dedicated orthodontic toothbrush (P35, Oral B Laboratories, Calif.). Sixty orthodontic patients, aged 10 to 16 years and wearing upper and lower fixed appliances, were screened and recruited with parental consent. After an oral soft tissue examination at baseline, the percentage of plaque-covered tooth surfaces and gingival bleeding sites were recorded using visible plaque and gingival bleeding indexes. Each subject was randomly allocated to one of three groups (n 5 20) with brushing sequences 1-2-3, 2-1-3, 3-2-1. The first brush was given 2 weeks after baseline (visit 1). The time interval for using each brush was 4 weeks at the end of which visible plaque and gingival bleeding indexes were recorded and a further prophylaxis given. Statistical analysis was undertaken with analysis of variance. Data were analyzed on a site-specific basis; buccal smooth and interproximal surfaces, lingual smooth and interproximal surfaces. At baseline the mean visible plaque index for all subjects were; buccal smooth, 52.5% (6 22.5%); buccal interproximal, 70.5% (6 18.5%); lingual smooth, 68.5% (6 21%); lingual interproximal, 76% (6 16%). At visit 1, the plaque scores at all surfaces had reduced significantly compared to baseline, but there had been no active treatment. This was attributed to a Hawthorne effect. Subsequently, there were no significant effects on visible plaque (or gingival bleeding) indexes with any toothbrush at any tooth surfaces. This suggests that the new HP550 is equally effective as specifically designed orthodontic toothbrushes in removing plaque from patients with fixed orthodontic appliances. (Am J Orthod Dentofacial Orthop 1998;114:45-49.)
T
he regular and effective removal of plaque from all surfaces of teeth, both above and below the gingival margin, is essential for the prevention of gingival and periodontal disease.1-3 Effective removal of plaque is compromised significantly when fixed orthodontic appliances are worn and the accumulation of plaque, and the development of gingivitis and gingival overgrowth are well-recognized problems.4-10 In some cases, a simple gingivitis may progress to destructive periodontitis although this does not appear to be a significant problem during orthodontic therapy in adolescents.11-15 In an attempt to facilitate plaque control in orthodontic patients, specifically designed manual and electric toothbrushes have been developed. From the Dental School at the University of Newcastle upon Tyne and the School of Health Science, University of Teesside. a Dental School, University of Newcastle upon Tyne. b School of Health Science, University of Teesside. Reprint requests to: Dr. P.A. Heasman, Restorative Dentistry, Dental School, Framlington Place, Newcastle upon Tyne, NE2 4BW, U.K. Copyright © 1998 by the American Association of Orthodontists. 0889-5406/98/$5.00 1 0 8/1/84774
Manual brushes with V-shaped longitudinal grooves in the brushing surface are intended to improve brushing around brackets and arch wires, although their effectiveness in reducing gingivitis compared with conventional brushes is questionable.16 Electric toothbrushes can improve plaque control without causing damage to the components of the orthodontic appliance. For example, rotary and counterrotational brushes have been shown to be particularly effective in plaque removal and reducing gingivitis in orthodontic patients.17-21 Improvements in the design of electric toothbrushes are constantly being sought and one recently marketed product, the Dental Logic HP550 (Philips DAP, Groningen, Netherlands), has incorporated several practical features that may be of value in improving plaque control around fixed appliances. These features include brush head movements in two directions and at two speeds simultaneously, and a unique, soft pressure gum protection system that regulates the amount of force (maximum 300 gm) that is applied to the teeth and gingiva. The brush (or brushhead) was 45
46 Heasman et al.
not, however, designed specifically for use by orthodontic patients. The aim of this study was to evaluate the efficacy of the HP550 Dental Logic brush, a manual orthodontic toothbrush, and a powered orthodontic toothbrush in decreasing plaque accumulation and gingival inflammation in a cohort of children undergoing orthodontic treatment. MATERIAL AND METHODS This is a three-period, three-treatment, balanced, Latin square-type, single-blind cross-over clinical trial of three toothbrushes with children undergoing fixed orthodontic treatment. Ethical approval for the protocol was granted by the Joint Ethics Committee of the Newcastle and North Tyneside Health Authorities. Sixty patients (males and females) between the ages of 10 and 16 years were recruited from the Department of Orthodontics at Newcastle Dental Hospital. All patients had started orthodontic treatment within the previous 12 months and had at least 12 brackets (or bands) on teeth in each arch. Written informed consent was given by the parent or legal guardian. Patients were excluded if they had 1. previously used an electric toothbrush or a manual orthodontic brush 2. a history of early onset periodontal disease, 3. a mental handicap, 4. a physical handicap that restricted free movement of hands or fingers 5. received oral hygiene instruction from a dental professional within the previous 6 months The patients were examined by a clinician (screening visit) for suitability and an information sheet was given to the parent or guardian. Enrollment for the baseline visit followed the provision of written consent. At baseline, 2 weeks after screening, each patient was allocated at random, to one of three groups (n 5 20) each with a sequenced three-period regimen of toothbrushing; each period of 4 weeks duration was associated with the use of one toothbrush. The trial toothbrushes were (1) Oral B manual orthodontic brush, (2) Braun electric toothbrush (D7, Braun AG, Germany) with orthodontic head OD5-1, (3) HP550 electric toothbrush with head HP5924. The sequence of treatments for each numerically balanced allocation of patients was 1-2-3, 2-1-3, 3-2-1. A standard, fluoride-containing dentifrice was given to all patients for use throughout the trial. Design At baseline an examination of the gingiva was undertaken for visible signs of abrasion, ulceration, swelling, or gingival recession. Plaque was scored with the Visible Plaque Index (VPI)22 at six sites around each tooth (mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual, distolingual). Gingival bleeding was scored at four
American Journal of Orthodontics and Dentofacial Orthopedics July 1998
sites around each tooth (mesial, buccal, lingual, distal) with the Gingival Bleeding Index (GBI).22 Bleeding was provoked by probing each site with a TPS (pressure sensitive) probe (Vivadent, Schaan, Leichtenstein). Patients were next seen (visit 1) 2 weeks after the baseline visit. Clinical scores and the oral examination were repeated. The fixed appliances were adjusted if required; to maintain the blind nature of the design and to prevent bias, instructions in the use of all three brushes were given (Z.W.). For the electric toothbrushes, the manufacturer’s instructions were read through with the patient; the purpose and design of the manual toothbrush were also discussed. A combination of the Bass and Charters techniques was taught diagrammatically with use of the manual toothbrush so that plaque was removed from the gingival sulcus and the gingival facing surface of brackets. The suggested brushing time for the electric toothbrushes was at least 3 minutes, twice daily. A minimum of 2 minutes brushing time (twice daily) was recommended for the manual toothbrush. The first brush in the sequence was then given to each patient and by a different researcher (P.H.) from the one who had given the instructions in toothbrushing. Appointment times for each visit were scheduled for between 2 and 3 hours after an episode of toothbrushing. At the conclusion of each 4-week brushing period, oral examination and clinical scores were repeated, and the orthodontic appliances adjusted where necessary. A dental prophylaxis given before the sequence was repeated for the second and third brushes. The clinical indexes were measured, and the instructions in using all three toothbrushes were repeated. On completion of the trial all patients continued with their orthodontic treatment. Repeatability Two research dental hygienists carried out the examinations and clinical scoring. A prestudy calibration (repeatability) exercise was undertaken scoring full mouth sites on each of five subjects (10 to 15 years old) who were not involved in the main study. The mean intraexaminer exact agreements for the examiners were VPI, 88% and 84%; GBI, 89% and 92%. The mean interexaminer exact agreements were VPI, 83%; GBI, 88%. Statistical analysis Statistical analysis was undertaken with analysis of variance with treatments for subject, period, and toothbrushing regimen. The VPI (primary outcome variable for toothbrush efficacy) was analyzed on a site-specific basis: buccal smooth (Bs) and interproximal (Bi) surfaces, lingual smooth (Ls) and interproximal (Li) surfaces. Good clinical practice The study conformed to guidelines for Good Clinical Practice. The study site and procedure were audited by an independent assessor on three occasions, and no breach of
Heasman et al. 47
American Journal of Orthodontics and Dentofacial Orthopedics Volume 114, No. 1
protocol occurred. The projected recruitment time for subjects into the trial was 3 months although the period was 6 months. This did not affect the outcome or completion of the study. Results
All subjects completed the study. The cohort comprised 21 males and 39 females with the mean age of 13.6 (6 1.2) years. Mean site specific plaque indexes and gingival indexes at baseline and visit 1 are shown in Table I. Plaque indexes at all sites at visit 1 were consistently and significantly lower than those at baseline (at p 5 0.05; t test). There were, however, no differences in bleeding scores between baseline and visit 1. Tables II and III show the VPI at smooth and interproximal sites respectively for the buccal and lingual tooth surfaces. Data are presented for each brush at the end of each brushing period (of 4 weeks), as well as for all brushes and for all periods. Table IV shows the full mouth gingival bleeding scores after the use of each brush at the end of each brushing period. The data for all brushes and all periods are also shown. In summary, there were no differences between the brushes in their efficacy in reducing plaque scores at buccal (smooth/interproximal) or lingual (smooth/interproximal) sites. Similarly, there were no differences between the brushes in their effect on gingival bleeding scores. There was no evidence of gingival trauma in any subject at any time during the study. DISCUSSION
The study was designed to test the plaque removing effects of a manual orthodontic toothbrush and two electric toothbrushes in a cohort of patients with fixed orthodontic appliances. The manual brush has a longitudinal groove in the brushing surface to facilitate brushing around brackets and arch wires. The Braun brush head OD5-1 is also designed to improve cleaning around fixed appliances and the brush moves with a rotating/oscillating motion. The brush head on the Philips HP550 moves simultaneously in two directions and at two speeds. This brush is not specifically recommended for patients with fixed orthodontic appliances but the brush head movements may be considered appropriate for cleaning the gingival crevice and interproximally, beneath components of an appliance. The Braun Plaque Control electric toothbrush (models D3, D5, and D7) has repeatedly been shown to remove more plaque than manual brushes in non-orthodontic patients in both cross-over and
Table I. Plaque scores (%) (mean 6 SD) at baseline and visit 1
VPI Buccal Smooth Interproximal Lingual Smooth Interproximal GBI
Baseline
Visit 1
Baseline—Visit 1
53 (623) 71 (619)
39 (620) 65 (618)
p , 0.001 p , 0.02
69 (621) 76 (616) 31 (619)
57 (621) 68 (618) 26 (616)
p , 0.01 p , 0.05 p . 0.05
VPI, Visible Plaque Index. GBI, Gingival Bleeding Index. SD, Standard deviation.
parallel studies.23-27 The more specific question regarding the value of electric brushes for orthodontic patients has received less attention, although a number of different designs have been tested and the brushes found to be efficacious when compared to manual brushes.17-21 Our cross-over design enabled each brush to be tested on each subject. This eliminated any potential for intersubject variation to result from different numbers of brackets or types of components in the appliance. The inclusion of three ‘groups’ with different sequences of brushing was designed to compensate for the absence of a ‘wash-out’ period. It was considered extremely unlikely, however, that the use of one brush would influence the use of any other because of the different techniques required for each toothbrush. One of the main variables in toothbrushing studies reported in the literature is the period of observation. A time interval of 4 weeks has been shown to be sufficient to observe meaningful changes in plaque and bleeding.28-30 Studies of longer duration are more likely to allow observations that reflect an individual’s long-term dental hygiene practices at home, but a more precise evaluation of the efficacy and potential of a toothbrush may be less apparent as the compliance of subjects becomes an additional variable. As the efficacy of the HP550 had, as far as we are aware, not been determined in controlled clinical studies, we opted for the shorter period of observation. Another variable between studies is the time spent brushing. We recommended that each subject use the manual brush for 2 minutes, twice a day. It has previously been shown that brushing for 2 minutes with an electric brush will reduce plaque scores by 75% to 88% depending on the brush design.31 As none of the subjects had previously used an electric toothbrush and in view of the potential difficulties in cleaning around fixed ortho-
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American Journal of Orthodontics and Dentofacial Orthopedics July 1998
Table II. Visible Plaque Index % scores (mean 6 SD) at smooth surfaces at the end of each experimental period Buccal
Manual brush Braun Electric OD5 Philips HP 550 All brushes
Lingual
Period 1
Period 2
Period 3
All periods
Period 1
Period 2
Period 3
All periods
39 (6 18) 39 (6 22) 39 (6 18) 39 (6 19)
— 42 (6 21) 32 (6 18) 38 (6 21)
28 (6 19) — 38 (6 20) 31 (6 32)
32 (6 19) 41 (6 21) 36 (6 20)
50 (6 24) 43 (6 26) 50 (6 20) 48 (6 24)
— 42 (6 22) 37 (6 18) 40 (6 21)
37 (6 19) — 48 (6 23) 41 (6 21)
42 (6 22) 43 (6 23) 45 (6 21)
SD, Standard deviation.
Table III. Visible Plaque Index % scores (mean 6 SD) at interproximal surfaces at the end of each experimental period Buccal
Manual brush Braun Electric OD5 Philips HP 550 All brushes
Lingual
Period 1
Period 2
Period 3
All periods
Period 1
Period 2
Period 3
All periods
61 (6 14) 61 (6 20) 64 (6 18) 62 (6 17)
— 59 (6 20) 63 (6 18) 60 (6 20)
59 (6 16) — 63 (6 13) 60 (6 15)
59 (6 16) 59 (6 20) 63 (6 16)
59 (6 22) 59 (6 17) 60 (6 21) 59 (6 19)
— 58 (6 22) 60 (6 14) 58 (6 19)
60 (6 16) — 62 (6 20) 61 (6 17)
60 (6 18) 58 (6 20) 60 (6 18)
SD, standard deviation.
Table IV. Full mouth Gingival Bleeding Index % scores (mean 6 SD) at the end of each experimental period
Manual brush Braun Electric OD5 Philips HP 550 All brushes
Period 1
Period 2
Period 3
All periods
21 (6 12) 20 (6 13)
— 16 (6 11)
14 (6 8) —
17 (6 10) 17 (6 12)
19 (6 12) 20 (6 12)
17 (6 10) 16 (6 11)
18 (6 9) 15 (6 9)
18 (6 10)
SD, Standard deviation.
dontic appliances, we increased the brushing time to 3 minutes when an electric brush was used. When designing the study, it was considered that the proximity of orthodontic bands and brackets to the gingival margin might complicate scoring of plaque. Plaque was therefore recorded dichotomously using the Visible Plaque Index rather than quantitatively, which is otherwise the preferred method in most longitudinal clinical trials. Plaque scores at all surfaces at baseline were greater than 50%, and our subjects therefore correspond to those considered to have ‘poor’ oral hygiene in the study of Heintze et al.21 This cross-over study of three electric and one manual brush found that over a 4 week period, the Braun Oral B and Rota-dent (Kusnacht, Switzerland) brushes were more efficacious in reducing full mouth plaque scores when compared with the Interplak (Bausch and Lomb, Germany) and a manual brush. When scores at specific surfaces were analyzed, however, none of the brushes demonstrated superiority.
The results of our study demonstrated equal efficacy in reducing plaque and gingival bleeding scores for the three products tested. No brush demonstrated superiority at either smooth or interproximal surfaces, although the plaque scores at smooth surfaces at baseline and thereafter were consistently lower compared with interproximal sites. The plaque scores for each brush at smooth and interproximal surfaces, regardless of the period and sequence of brushing, were consistently lower than those at baseline but virtually identical to those at visit 1. Indeed, the mean plaque scores at all surfaces at visit 1 were consistently and significantly lower than scores at baseline (p , 0.05; Table I). As none of the test brushes was used until visit 1 and no alteration in oral hygiene practices was recommended at baseline, the reduction in plaque scores observed between these visits is attributed to the Hawthorne effect.32 This change in behavior of subjects who anticipate involvement in a clinical trial has been observed previously and may be a source of variability for cross-over designs.33 We believe that this observation alone justifies the inclusion of the pretest period between screening and the first experimental period to allow a short period for Hawthorne stabilization. There was no significant difference between full mouth gingival bleeding scores at baseline and visit 1; this suggests that the reduction in plaque scores over the same period was clinically insignificant and insufficient to affect resolution of the inflammatory response. This apparent lack of correlation between
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plaque and gingivitis scores has also been observed by other workers.30,34 CONCLUSION This 4 week, cross-over study demonstrated that the Philips HP550, the dedicated electric Braun D7, and the manual (Oral B) orthodontic brushes were equally effective in removing plaque and reducing gingival inflammation as indicated by bleeding on probing in patients undergoing fixed orthodontic treatment. This suggests that further research is necessary to improve the designs of orthodontic toothbrushes. Clinicians and hygienists should appreciate that dedicated brushes may offer no advantages in cleaning interproximally and in the gingival crevice. REFERENCES 1. Suomi JD, Greene JC, Vermillion JR, Doyle JJ, Chang J, Leatherwood EC. The effect of controlled oral hygiene procedures on the progression of periodontal disease in adults: results after third and final year. J Periodontol 1971;42:152-60. 2. Nyman S, Rosling B, Lindhe J. Effect of professional tooth cleaning on healing after periodontal surgery. J Clin Periodontol 1975;2:80-6. 3. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. J Clin Periodontol 1981;8:239-48. 4. Baer PN, Coccaro PJ. Gingival enlargement coincident with orthodontic therapy. J Periodontol 1964;35:436-9. 5. Zachrisson BU, Zachrisson S. Caries incidence and orthodontic treatment with fixed appliances. Scand J Dent Res 1971;79:183-92. 6. Zachrisson BU, Zachrisson S. Caries incidence and oral hygiene during orthodontic treatment. Scand J Dent Res 1971;79:394-401. 7. Zachrisson S, Zachrisson BU. Gingival conditions associated with orthodontic treatment. Angle orthod 1972;42:26-34. 8. Shelley WB. Gingival hyperplasia from dental braces. Cutis 1981;28:149-50. 9. Legott PJ, Boyd RL, Quinn RS, Eakle WS, Chambers DW. Gingival disease pattern during fixed orthodontic treatment adolescents v adults. J Dent Res 1984;63:309. 10. Huser MC, Baehni PC, Lang R. Effects of orthodontic bands on microbiological and clinical parameters. Am J Orthod Dentofacial Orthop 1990;97:213-8. 11. Zachrisson BU, Alnaes L. Orthodontic conditions in orthodontically treated and untreated children. I. loss of attachment, gingival pocket depth and clinical crown height. Angle Orthod 1973;43:402-11. 12. Alstad S, Zachrisson BU. Longitudinal study of periodontal condition associated with orthodontic treatment in adolescents. Am J Orthod 1979;76:277-86. 13. Trossello VK, Gianelly AA. Orthodontic treatment and periodontal status. J Periodontol 1979;50:665-71. 14. Sadowsky C, BeGole EA. Long-term effects of orthodontic treatment on periodontal health. Am J Orthod 1981;80:156-70.
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