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One Type of Powered Toothbrush may be More Effective Than Others in Controlling Plaque and Gingivitis
REVIEW ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Different powered toothbrushes for plaque control and gingival health. Deacon SA, Glenny AM, Deery C, Robinson PG, Heanue M, Walmsley AD, Shaw WC. Cochrane Database Syst Rev 2010;(12): CD004971.
REVIEWER Earl Ernest Guile, DMD, MPH
PURPOSE/QUESTION To compare the relative efficacy of various types of powered toothbrushes in reducing plaque and gingivitis and to assess other performance factors such as stain removal, cost, reliability, and safety
SOURCE OF FUNDING Institutional support from numerous dental schools and research centers from the United Kingdom, including University of Manchester, University of Birmingham, University of Sheffield, University of Bristol, Edinburgh Dental Institute, North Bristol NHS Trust, Manchester Academic Health Sciences Centre (MAHSC), and NIHR Manchester Biomedical Research Centre
TYPE OF STUDY/DESIGN Systematic review with meta-analysis of data
LEVEL OF EVIDENCE Level 2: Limited-quality, patientoriented evidence
STRENGTH OF RECOMMENDATION GRADE Grade B: Inconsistent or limitedquality patient-oriented evidence J Evid Base Dent Pract 2012;12:65-68 1532-3382/$36.00 Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2012.03.004
One Type of Powered Toothbrush may be More Effective Than Others in Controlling Plaque and Gingivitis SUMMARY Selection Criteria In this review, 2 or more powered toothbrushes with different mechanical modalities of action were compared for efficacy in reducing plaque and gingivitis. Seven reviewers evaluated 7 databases (The Cochrane Oral Health Group’s Trials Register, The Cochrane Central Register of Controlled Trials, The Cochrane Library 2010, Issue 3, MEDLINE via OVID, EMBASE via OVID, CINAHL via EBSCO) without language restriction for studies comparing powered toothbrushes. The reviewers also manually checked Journal of Dental Research and The Journal of Dentistry. There were 396 studies initially identified, and after analysis only 64 were eligible for analysis. A total of only 17 of the 64 were deemed complete enough for inclusion in the review. Study authors were contacted from 11 of the studies for additional information. All studies were not forthcoming with new information in time; therefore, plans were made to add more information in a future updated review. The studies selected were restricted to randomized controlled trials with the inclusion of crossover designs and the exclusion of split-mouth designs. All trials included lasted a minimum of 28 days. A short-term trial ranged between 4 weeks and 3 months and a long-term trial lasted longer than 3 months. The total number participants in the 17 trials was 1369, with 71 lost to follow-up. No particular ages were specified, and participants had no known disabilities that would interfere with toothbrushing.
Key Study Factor The key factor studied was relative efficacy of two or more modes of powered brushing. The types of powered brushing included side-to-side, counter oscillation, circular, rotation oscillation, ultrasonic, and multidimensional. The study comparisons were as follows: side-to-side versus counter oscillation (2 studies), side-to-side versus rotation oscillation (7 studies), multidimensional versus rotation oscillation (3 studies), multidimensional versus side-to-side (3 studies), counter oscillation versus rotation oscillation (1 study), counter oscillation versus circular (1 study), and side-to-side versus circular (1 study). Fourteen studies used full-mouth design and 3 studies involved partial-mouth design in evaluating plaque and gingivitis. The statistical measure used to compare differences in plaque and gingivitis reduction from the different types of powered brushes treatment groups was the standardized mean difference (SMD) along with 95% confidence intervals (CIs) using the random-effects model. Likely causes of heterogeneity were assessed. Comparing means is the basis of metaanalyses where continuous variables are the outcome measures. The difference between the mean of each group is the basic way of comparing outcomes from 2 treatment groups. Each meta-analysis used the SMD as the effect measure.1 In using the SMD, it is important that the different measurement scales are indeed measuring the same clinical outcome. In this meta-analysis, only those studies meeting this criterion were included.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
Main Outcome Measure The main outcome measures were the quantified level of gingivitis and plaque resulting from the respondent’s use of various types of powered toothbrushes. Specifically, the modes of action of the toothbrushes were compared regarding (1) removal of plaque, (2) health of the gingiva, and (3) adverse effects. Evaluations were made in both the short (0-3 months) and long term (> 3 months) and these measures were considered proxies for the risk of incurring both caries and periodontal disease. The Turesky modification of the Quigley-Hein Plaque Index2 was used to measure plaque levels and the Gingival Index of L€ oe and Silness3 was used to measure gingivitis. Alternatively, if the Gingival Index was not available, the bleeding on probing of Ainamo and Bay4 was used.
Main Results A total of 17 trials were included in the review and 371 studies were excluded. The results are summarized as follows: Side-to-side versus counter oscillation5-6—There was no statistically significant difference for plaque (SMD –0.02; 95% confidence interval [CI] –0.37 to 0.32) and gingivitis (SMD –0.02; 95% CI –0.37 to 0.32). Long-term data were not reported. Side-to-side versus rotation oscillation7-13—There was a statistically significant difference for rotation oscillation toothbrushes in comparison with side-to-side for short-term plaque reduction (SMD 0.24; 95% CI 0.02 to 0.46). The CI for the meta-analysis for effects on gingivitis only included zero (SMD 0.35 CI –0.04 to 0.74). This suggests that the rotation oscillation may also be better at reducing gingivitis. Side-to-side versus circular13—There was no significant reduction short term for plaque reduction. There was significant difference short term for gingivitis reduction by the circular mode (SMD 0.89; 95% CI 0.38 to 1.41) Counter oscillation versus rotation oscillation14—Data did not permit meta-analysis; however, there was no significant difference between counter-oscillation and rotationoscillation brushes (P values ranged from 0.06 to 0.75) for any of the reported outcomes. Counter oscillation versus circular14—No meta-analysis could be used; however, there was significant difference in favor of counter oscillation over circular. Rotation oscillation versus circular13,14—There was no significant difference short term between the modes of action for the reduction of plaque (SMD –0.02; 95% CI –0.51 to 0.47). There was a significant difference with respect to reducing gingivitis in favor of the circular mode of action (SMD 0.87; 95% CI 0.36 to 1.39). Multidimensional versus side-to-side15-17—Because of significant heterogeneity in the studies, no pooling of data was done (P < .1; I2 = 96%). 66
Multidimensional versus rotation oscillation18-20—For short-term analysis, no significant difference was shown between the modes of action. Ultrasonic versus multidimensional21—Data were not usable from this one study. Regarding secondary outcomes, cost and reliability were not reported in the trials analyzed in this review. For calculus, rotation oscillation was reported to be significantly better in reducing lower lingual incisor calculus than side-to-side during the short term.10
Conclusions After reviewing 17 trials, rotation oscillation brushes in the short term reduce plaque and gingivitis more than side-to-side brushes. This was statistically significant but not necessarily clinically significant. A previous review indicated that rotation oscillation was superior to manual brushing.22 The most effective powered toothbrush was not made clear from this review. Additional trials with a focus on long-term effects of the different modes of action are needed. Furthermore, indices for plaque and gingivitis of future trials should be standardized so that pooling of data can be better for meta-analysis. This research could establish a preference for powered toothbrushing.
COMMENTARY AND ANALYSIS The public is oriented toward using new technologies. Powered toothbrushes come in many styles and modes of action, and the public is sometimes confused as to which style is best to purchase. Dentists are obligated to advise patients when questions are asked on toothbrush efficacy. This review asks the question of which type of powered toothbrush provides the best control of plaque and gingivitis. Previous reviews have compared powered toothbrushes to manual toothbrushes and those reviews have given a slight edge to the powered toothbrushes.22 Additionally, a recent review in the Journal of EvidenceBased Dental Practice concluded that there was no difference regarding hard and/or soft tissue safety between powered toothbrushes and manual toothbrushes.23 The current systematic review conducted by Deacon et al, focuses on head-to-head comparisons between types of powered toothbrushes. The authors’ overall conclusions do not support the selection of a particular type of powered toothbrush as superior to others. Although I agree with these conclusions, this systematic review is merely a start and does not presently contribute significantly to the evidence-based dentistry literature. When the data were pooled and made homogeneous, better results were achieved from rotation oscillation style brushes in comparison with side-to-side brushes. This evidence was achieved only short term for plaque reduction. Turesky plaque scores were reduced by 7% in the metaanalysis of data from one of the trials when rotation June 2012
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
oscillation was compared to side-to-side powered toothbrushes. Although practitioners can explain to patients that rotation oscillation toothbrushes may offer a slight advantage, it is not clear what the clinical significance of this would be. The weakness of this review is based on the limited studies that were included and the lack of sufficient trials longer than 3 months. Another weakness was the grouping of the toothbrushes by modes of action. This desire to increase the power of the meta-analysis resulted in less capability of distinguishing subtle differences between the brushes. Other factors were not analyzed, such as shape and size of the brush; and the orientation, size, and flexibility of the bristles. These factors should be included in the future. Because of the short length of the trials, disease outcomes could not be measured. This is an important consideration for future research, given that ‘‘patient-oriented’’ outcomes are critical for producing evidence-based guidelines for dental clinicians. The ascertainment of study quality for this systematic review followed a detailed regimen and was rigorous. Assessment of potential bias within the included trials was conducted independently by at least 2 reviewers as part of data extraction. Some of the key elements assessed from the included trials included randomization scheme, concealment of treatment allocation, and blinding. The risk of bias was accessed using kappa statistics, and it was determined that 13 of the studies had an unclear risk of bias, 2 studies had a high risk of bias, and no study had a low risk of bias. This result further precludes any definitive conclusions. The quality assessment and bias risk findings reported from this systematic review indicate that future trials investigating powered toothbrushes not only use the Consolidated Standards of Reporting Trials (CONSORT)24 to standardize reporting, but to improve study design and report on relevant measures in such a way that more robust meta-analyses on well-conducted randomized controlled trials can be undertaken. The statistical measure used, the standardized mean difference, should be continued in the future. Future trials should consider correcting the weaknesses of the present collection by increasing the sample sizes and lengthening the study period beyond 3 months. In addition to these adjustments, there should also be changes made in the outcome measures. In addition to the short-term clinical outcomes of plaque levels and gingival status, longer-term outcomes of periodontal disease and caries levels should be considered in view of the longer study period. Furthermore, nonclinical outcomes, such as respondent satisfaction, cost benefit, reliability, and adverse effects should be more rigorously embedded in the future research protocol. The above improvements in the research with more definitive results would provide dental practitioners and the public with unambiguous guidelines of toothbrush choice that could potentially enhance the oral health of Volume 12, Number 2
the public. Precise decisions on which type of toothbrush to buy and the relative advantages of the various types could be made. This would align what a consumer is most satisfied with along with a device that would be optimal for long-term oral health. If these factors are present, the public would more likely use the devices regularly, and reaching the goal of preserving healthy hard and soft oral structures would have a higher probability. The key finding in this study indicates that rotation oscillation–powered toothbrushes provides a marginal advantage to side-to-side powered toothbrushes in removing plaque and reducing gingivitis. The evidence in this review is weak and does not constitute a definite preference for one type of powered toothbrush over another.
REFERENCES 1. Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. In: Egger M, Davey Smith G, Altman DG, editors. Systematic reviews in health care: meta-analysis in context. 2nd ed. London: BMJ; 2001. 2. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of vitamin C. J Periodontol 1970;41(1):41-3. 3. L€ oe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51. 4. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25(4):229-35. 5. Khocht A, Spindel L, Person P. A comparative clinical study of the safety and efficacy of three toothbrushes. J Periodontol 1992;63(7), 6030-10. 6. Shibly O, Schifferle RE, Ciancio SG, Tarakji M, Mather ML. A clinical comparison of 2 electric toothbrush designs. J Clin Periodontol 1997;24(4):260-3. 7. Goyal CR, Qaqish J, He T, Grender J, Walters P, Biesbrock AR. A randomized 12-week study to compare the gingivitis and plaque reduction benefits of a rotation-oscillation power toothbrush and a sonic power toothbrush. J Clin Dent 2009;20(3):93-8. 8. Grossman E, Dembling W, Proskin HM. A comparative clinical investigation of the safety and efficacy of an oscillating/rotating electric toothbrush and a sonic toothbrush. J Clin Dent 1995;6(1):108-12. 9. Hefti AF, Stone C. Power toothbrushes, gender, and dentin hypersensitivity. Clin Oral Invest 2000;4(2):91-7. 10. Isaacs RL, Beiswanger BB, Rosenfield ST, Crawford JL, Mau MS, Eckert GJ, et al. A crossover clinical investigation of the safety and efficacy of a new oscillating/rotating electric toothbrush and a highfrequency electric toothbrush. Am J Dent 1998;11(1):7-12. 11. Robinson PJ, Maddalozzo D, Breslin S. A six-month clinical comparison of the efficacy of the Sonicare and the Braun Oral-B electric toothbrushes on improving periodontal health in adult periodontitis patients. J Clin Dent 1997;8(1 Spec No):4-9. 12. Williams K, Walters PA, Bartizek RD, Biesbrock AR. The reduction of gingivitis using battery-powered toothbrushes over a one-month period. J Clin Dent 2002;13(5):207-10. 13. Yankell SL, Emling RC. A thirty-day safety and efficacy evaluation of the Rowenta, Braun and Sonicare powered toothbrushes and a manual toothbrush. J Clin Dent 1997;8(4):120. 14. Trimpeneers LM, Wijgaerts IA, Grognard NA, Dermaut LR, Adriaens PA. Effect of electric toothbrushes versus manual toothbrushes on removal of plaque and periodontal status during orthodontic treatment. Am J Orthod Dentofac Orthop 1997; 111(5):492-7.
67
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE 15. Goyal CR, Sharma NC, Qaqish JG, Cugini MA, Thompson MC, Warren PR. Efficacy of a novel brush head in the comparison of two power toothbrushes on removal of plaque and naturally occurring extrinsic stain. J Dent 2005;33(Suppl 1):37-43. 16. Patters MR, Bland PS, Shiloah J, Blankenship JA, Scarbecz M. Comparison of the Hydrabrush powered toothbrush with two commercially-available powered toothbrushes. J Int Acad Periodontol 2005;7(3):80-9. 17. Zimmer S, Strauss J, Bizhang M, Krage T, Raab WH, Barthel C. Efficacy of the Cybersonic in comparison with the Braun 3D Excel and a manual toothbrush. J Clin Periodontol 2005;32(4):360-3. 18. Heasman PA, Stacey F, Heasman L, Sellers P, Macgregor ID, Kelly PJ. A comparative study of the Philips HP 735, Braun Oral B D7 and the Oral B 35 Advantage toothbrushes. J Clin Periodontol 1999;26(2): 85-90. 19. Thienpont V, Dermaut LR, Van Maele G. Comparative study of 2 electric and 2 manual toothbrushes in patients with fixed orthodontic appliances. Am J Orthod Dentofac Orthop 2001;120(4):353-60. 20. Williams K, Rapley K, Haun J, Walters P, He T, Grender J, et al. Comparison of rotation/oscillation and sonic power toothbrushes on plaque and gingivitis for 10 weeks. Am J Dent 2009;22(6):345-9.
68
21. Costa MR, Silva VC, Miqui MN, Sakima T, Spolidorio DMP, Cirelli JA. Efficacy of ultrasonic, electric and manual toothbrushes in patients with fixed orthodontic appliances. Angle Orthod 2007;77(2):361-6. 22. Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, et al. Manual versus powered toothbrushing for oral health. Cochrane Database Sys Rev 2005;(2):CD002281. 23. Farsi NJ, Nicolau B. There is no difference with regard to hard and/ or soft tissue safety between oscillating-rotating powered brushes and manual toothbrushes J. Evid Based Dent Pract 2011;11(4):168-70. 24. Schulz KF, Altman DG, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. J Clin Epidemiol 2010;63(8):834-40.
REVIEWER Earl Ernest Guile, DMD, MPH Diplomate, American Board of Dental Public Health, Consultant, PO Box 91086, Portland, OR 97291 Phone: 503-267-6211 (cell), 503-533-0914 (home) [email protected]
June 2012
REVIEWER Earl Ernest Guile, DMD, MPH
PURPOSE/QUESTION To compare the relative efficacy of various types of powered toothbrushes in reducing plaque and gingivitis and to assess other performance factors such as stain removal, cost, reliability, and safety
SOURCE OF FUNDING Institutional support from numerous dental schools and research centers from the United Kingdom, including University of Manchester, University of Birmingham, University of Sheffield, University of Bristol, Edinburgh Dental Institute, North Bristol NHS Trust, Manchester Academic Health Sciences Centre (MAHSC), and NIHR Manchester Biomedical Research Centre
TYPE OF STUDY/DESIGN Systematic review with meta-analysis of data
LEVEL OF EVIDENCE Level 2: Limited-quality, patientoriented evidence
STRENGTH OF RECOMMENDATION GRADE Grade B: Inconsistent or limitedquality patient-oriented evidence J Evid Base Dent Pract 2012;12:65-68 1532-3382/$36.00 Ó 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2012.03.004
One Type of Powered Toothbrush may be More Effective Than Others in Controlling Plaque and Gingivitis SUMMARY Selection Criteria In this review, 2 or more powered toothbrushes with different mechanical modalities of action were compared for efficacy in reducing plaque and gingivitis. Seven reviewers evaluated 7 databases (The Cochrane Oral Health Group’s Trials Register, The Cochrane Central Register of Controlled Trials, The Cochrane Library 2010, Issue 3, MEDLINE via OVID, EMBASE via OVID, CINAHL via EBSCO) without language restriction for studies comparing powered toothbrushes. The reviewers also manually checked Journal of Dental Research and The Journal of Dentistry. There were 396 studies initially identified, and after analysis only 64 were eligible for analysis. A total of only 17 of the 64 were deemed complete enough for inclusion in the review. Study authors were contacted from 11 of the studies for additional information. All studies were not forthcoming with new information in time; therefore, plans were made to add more information in a future updated review. The studies selected were restricted to randomized controlled trials with the inclusion of crossover designs and the exclusion of split-mouth designs. All trials included lasted a minimum of 28 days. A short-term trial ranged between 4 weeks and 3 months and a long-term trial lasted longer than 3 months. The total number participants in the 17 trials was 1369, with 71 lost to follow-up. No particular ages were specified, and participants had no known disabilities that would interfere with toothbrushing.
Key Study Factor The key factor studied was relative efficacy of two or more modes of powered brushing. The types of powered brushing included side-to-side, counter oscillation, circular, rotation oscillation, ultrasonic, and multidimensional. The study comparisons were as follows: side-to-side versus counter oscillation (2 studies), side-to-side versus rotation oscillation (7 studies), multidimensional versus rotation oscillation (3 studies), multidimensional versus side-to-side (3 studies), counter oscillation versus rotation oscillation (1 study), counter oscillation versus circular (1 study), and side-to-side versus circular (1 study). Fourteen studies used full-mouth design and 3 studies involved partial-mouth design in evaluating plaque and gingivitis. The statistical measure used to compare differences in plaque and gingivitis reduction from the different types of powered brushes treatment groups was the standardized mean difference (SMD) along with 95% confidence intervals (CIs) using the random-effects model. Likely causes of heterogeneity were assessed. Comparing means is the basis of metaanalyses where continuous variables are the outcome measures. The difference between the mean of each group is the basic way of comparing outcomes from 2 treatment groups. Each meta-analysis used the SMD as the effect measure.1 In using the SMD, it is important that the different measurement scales are indeed measuring the same clinical outcome. In this meta-analysis, only those studies meeting this criterion were included.
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
Main Outcome Measure The main outcome measures were the quantified level of gingivitis and plaque resulting from the respondent’s use of various types of powered toothbrushes. Specifically, the modes of action of the toothbrushes were compared regarding (1) removal of plaque, (2) health of the gingiva, and (3) adverse effects. Evaluations were made in both the short (0-3 months) and long term (> 3 months) and these measures were considered proxies for the risk of incurring both caries and periodontal disease. The Turesky modification of the Quigley-Hein Plaque Index2 was used to measure plaque levels and the Gingival Index of L€ oe and Silness3 was used to measure gingivitis. Alternatively, if the Gingival Index was not available, the bleeding on probing of Ainamo and Bay4 was used.
Main Results A total of 17 trials were included in the review and 371 studies were excluded. The results are summarized as follows: Side-to-side versus counter oscillation5-6—There was no statistically significant difference for plaque (SMD –0.02; 95% confidence interval [CI] –0.37 to 0.32) and gingivitis (SMD –0.02; 95% CI –0.37 to 0.32). Long-term data were not reported. Side-to-side versus rotation oscillation7-13—There was a statistically significant difference for rotation oscillation toothbrushes in comparison with side-to-side for short-term plaque reduction (SMD 0.24; 95% CI 0.02 to 0.46). The CI for the meta-analysis for effects on gingivitis only included zero (SMD 0.35 CI –0.04 to 0.74). This suggests that the rotation oscillation may also be better at reducing gingivitis. Side-to-side versus circular13—There was no significant reduction short term for plaque reduction. There was significant difference short term for gingivitis reduction by the circular mode (SMD 0.89; 95% CI 0.38 to 1.41) Counter oscillation versus rotation oscillation14—Data did not permit meta-analysis; however, there was no significant difference between counter-oscillation and rotationoscillation brushes (P values ranged from 0.06 to 0.75) for any of the reported outcomes. Counter oscillation versus circular14—No meta-analysis could be used; however, there was significant difference in favor of counter oscillation over circular. Rotation oscillation versus circular13,14—There was no significant difference short term between the modes of action for the reduction of plaque (SMD –0.02; 95% CI –0.51 to 0.47). There was a significant difference with respect to reducing gingivitis in favor of the circular mode of action (SMD 0.87; 95% CI 0.36 to 1.39). Multidimensional versus side-to-side15-17—Because of significant heterogeneity in the studies, no pooling of data was done (P < .1; I2 = 96%). 66
Multidimensional versus rotation oscillation18-20—For short-term analysis, no significant difference was shown between the modes of action. Ultrasonic versus multidimensional21—Data were not usable from this one study. Regarding secondary outcomes, cost and reliability were not reported in the trials analyzed in this review. For calculus, rotation oscillation was reported to be significantly better in reducing lower lingual incisor calculus than side-to-side during the short term.10
Conclusions After reviewing 17 trials, rotation oscillation brushes in the short term reduce plaque and gingivitis more than side-to-side brushes. This was statistically significant but not necessarily clinically significant. A previous review indicated that rotation oscillation was superior to manual brushing.22 The most effective powered toothbrush was not made clear from this review. Additional trials with a focus on long-term effects of the different modes of action are needed. Furthermore, indices for plaque and gingivitis of future trials should be standardized so that pooling of data can be better for meta-analysis. This research could establish a preference for powered toothbrushing.
COMMENTARY AND ANALYSIS The public is oriented toward using new technologies. Powered toothbrushes come in many styles and modes of action, and the public is sometimes confused as to which style is best to purchase. Dentists are obligated to advise patients when questions are asked on toothbrush efficacy. This review asks the question of which type of powered toothbrush provides the best control of plaque and gingivitis. Previous reviews have compared powered toothbrushes to manual toothbrushes and those reviews have given a slight edge to the powered toothbrushes.22 Additionally, a recent review in the Journal of EvidenceBased Dental Practice concluded that there was no difference regarding hard and/or soft tissue safety between powered toothbrushes and manual toothbrushes.23 The current systematic review conducted by Deacon et al, focuses on head-to-head comparisons between types of powered toothbrushes. The authors’ overall conclusions do not support the selection of a particular type of powered toothbrush as superior to others. Although I agree with these conclusions, this systematic review is merely a start and does not presently contribute significantly to the evidence-based dentistry literature. When the data were pooled and made homogeneous, better results were achieved from rotation oscillation style brushes in comparison with side-to-side brushes. This evidence was achieved only short term for plaque reduction. Turesky plaque scores were reduced by 7% in the metaanalysis of data from one of the trials when rotation June 2012
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
oscillation was compared to side-to-side powered toothbrushes. Although practitioners can explain to patients that rotation oscillation toothbrushes may offer a slight advantage, it is not clear what the clinical significance of this would be. The weakness of this review is based on the limited studies that were included and the lack of sufficient trials longer than 3 months. Another weakness was the grouping of the toothbrushes by modes of action. This desire to increase the power of the meta-analysis resulted in less capability of distinguishing subtle differences between the brushes. Other factors were not analyzed, such as shape and size of the brush; and the orientation, size, and flexibility of the bristles. These factors should be included in the future. Because of the short length of the trials, disease outcomes could not be measured. This is an important consideration for future research, given that ‘‘patient-oriented’’ outcomes are critical for producing evidence-based guidelines for dental clinicians. The ascertainment of study quality for this systematic review followed a detailed regimen and was rigorous. Assessment of potential bias within the included trials was conducted independently by at least 2 reviewers as part of data extraction. Some of the key elements assessed from the included trials included randomization scheme, concealment of treatment allocation, and blinding. The risk of bias was accessed using kappa statistics, and it was determined that 13 of the studies had an unclear risk of bias, 2 studies had a high risk of bias, and no study had a low risk of bias. This result further precludes any definitive conclusions. The quality assessment and bias risk findings reported from this systematic review indicate that future trials investigating powered toothbrushes not only use the Consolidated Standards of Reporting Trials (CONSORT)24 to standardize reporting, but to improve study design and report on relevant measures in such a way that more robust meta-analyses on well-conducted randomized controlled trials can be undertaken. The statistical measure used, the standardized mean difference, should be continued in the future. Future trials should consider correcting the weaknesses of the present collection by increasing the sample sizes and lengthening the study period beyond 3 months. In addition to these adjustments, there should also be changes made in the outcome measures. In addition to the short-term clinical outcomes of plaque levels and gingival status, longer-term outcomes of periodontal disease and caries levels should be considered in view of the longer study period. Furthermore, nonclinical outcomes, such as respondent satisfaction, cost benefit, reliability, and adverse effects should be more rigorously embedded in the future research protocol. The above improvements in the research with more definitive results would provide dental practitioners and the public with unambiguous guidelines of toothbrush choice that could potentially enhance the oral health of Volume 12, Number 2
the public. Precise decisions on which type of toothbrush to buy and the relative advantages of the various types could be made. This would align what a consumer is most satisfied with along with a device that would be optimal for long-term oral health. If these factors are present, the public would more likely use the devices regularly, and reaching the goal of preserving healthy hard and soft oral structures would have a higher probability. The key finding in this study indicates that rotation oscillation–powered toothbrushes provides a marginal advantage to side-to-side powered toothbrushes in removing plaque and reducing gingivitis. The evidence in this review is weak and does not constitute a definite preference for one type of powered toothbrush over another.
REFERENCES 1. Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. In: Egger M, Davey Smith G, Altman DG, editors. Systematic reviews in health care: meta-analysis in context. 2nd ed. London: BMJ; 2001. 2. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of vitamin C. J Periodontol 1970;41(1):41-3. 3. L€ oe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51. 4. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25(4):229-35. 5. Khocht A, Spindel L, Person P. A comparative clinical study of the safety and efficacy of three toothbrushes. J Periodontol 1992;63(7), 6030-10. 6. Shibly O, Schifferle RE, Ciancio SG, Tarakji M, Mather ML. A clinical comparison of 2 electric toothbrush designs. J Clin Periodontol 1997;24(4):260-3. 7. Goyal CR, Qaqish J, He T, Grender J, Walters P, Biesbrock AR. A randomized 12-week study to compare the gingivitis and plaque reduction benefits of a rotation-oscillation power toothbrush and a sonic power toothbrush. J Clin Dent 2009;20(3):93-8. 8. Grossman E, Dembling W, Proskin HM. A comparative clinical investigation of the safety and efficacy of an oscillating/rotating electric toothbrush and a sonic toothbrush. J Clin Dent 1995;6(1):108-12. 9. Hefti AF, Stone C. Power toothbrushes, gender, and dentin hypersensitivity. Clin Oral Invest 2000;4(2):91-7. 10. Isaacs RL, Beiswanger BB, Rosenfield ST, Crawford JL, Mau MS, Eckert GJ, et al. A crossover clinical investigation of the safety and efficacy of a new oscillating/rotating electric toothbrush and a highfrequency electric toothbrush. Am J Dent 1998;11(1):7-12. 11. Robinson PJ, Maddalozzo D, Breslin S. A six-month clinical comparison of the efficacy of the Sonicare and the Braun Oral-B electric toothbrushes on improving periodontal health in adult periodontitis patients. J Clin Dent 1997;8(1 Spec No):4-9. 12. Williams K, Walters PA, Bartizek RD, Biesbrock AR. The reduction of gingivitis using battery-powered toothbrushes over a one-month period. J Clin Dent 2002;13(5):207-10. 13. Yankell SL, Emling RC. A thirty-day safety and efficacy evaluation of the Rowenta, Braun and Sonicare powered toothbrushes and a manual toothbrush. J Clin Dent 1997;8(4):120. 14. Trimpeneers LM, Wijgaerts IA, Grognard NA, Dermaut LR, Adriaens PA. Effect of electric toothbrushes versus manual toothbrushes on removal of plaque and periodontal status during orthodontic treatment. Am J Orthod Dentofac Orthop 1997; 111(5):492-7.
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REVIEWER Earl Ernest Guile, DMD, MPH Diplomate, American Board of Dental Public Health, Consultant, PO Box 91086, Portland, OR 97291 Phone: 503-267-6211 (cell), 503-533-0914 (home) [email protected]
June 2012