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Clinical question.
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Are power toothbrushes more effective than manual toothbrushes in reducing gingival inflammation in orthodontic patients?
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Review methods.
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The authors performed a comprehensive, all-language literature search of multiple databases from 1950 through 2007, including those used for dissertations, conference proceedings and research registries (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Reviews, Cochrane Central Register of Controlled Trials, ISI Web of Knowledge, TrialsCentral and metaRegister of Controlled Trials). They included all randomized trials involving patients undergoing orthodontic treatment. The authors excluded all trials that combined toothbrushing with the use of antimicrobial mouthrinses, irrigation devices or interdental cleaning appliances. In addition, they excluded studies of less than four weeks’ duration. They also excluded trials with split-mouth designs and crossover trials with washout periods of less than one month. The authors used quantitative measurements of gingival inflammation (either gingival index scores or gingival bleeding scores) as outcome measures.
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Main results.
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Of 59 studies identified as potentially relevant, five met the inclusion criteria. The authors of these five studies investigated various types of power brushes. Only investigators in the trial that examined the side-to-side power toothbrush found a significant reduction in gingival scores. On the basis of the Löe and Silness gingival index,1 the reduction was approximately 0.5 point.
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Conclusion.
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The evidence is insufficient regarding whether power toothbrushes are more effective than manual toothbrushes for orthodontic patients.
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COMMENTARY
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Importance and context.
Maintaining good oral hygiene during orthodontic treatment is a challenge, and many orthodontists prescribe power toothbrushes to their patients in an effort to prevent gingival inflammation, decalcification and caries. The results of this review, however, do not indicate clear benefits from using power toothbrushes rather than manual toothbrushes, at least for the duration of the trials (the longest of which was 60 days).
Strengths and weaknesses of the systematic review.
The authors clearly stated the research question, and they conducted a comprehensive search of multiple databases. They also stated the criteria for inclusion and exclusion, and two investigators reviewed each study independently. The outcome—gingival health—was appropriate; however, one might consider plaque scores to be equally relevant, because plaque is thought to be a precursor of both caries and gingivitis.
Strengths and weaknesses of the evidence.
The five studies included in this review were randomized trials. The authors of only one of the five trials, the trial with the fewest participants (12 per group) and the shortest duration (one month), reported that side-to-side power toothbrushes were more effective than manual toothbrushes. The investigators in the other four studies, which had larger patient populations (> 25 per group) and a longer duration (one to two months), found no difference between power and manual toothbrushes. The overall quality of the studies was poor to moderate. Because orthodontic treatment often lasts several years, studies of longer duration are needed.
Implications for dental practice.
In another review, Sicilia and colleagues2 assessed 21 randomized trials composed of adults in the general population; 10 of these trials demonstrated that power toothbrushes were more effective than manual toothbrushes in reducing gingival bleeding or inflammation. The results of these studies revealed that counter-rotational or rotating-oscillating brushes were more effective, although the reductions in bleeding and gingivitis varied from 10 percent to more than 60 percent. This heterogeneity of results precluded a meta-analysis.
The results of a review by Robinson and colleagues,3 which consisted of 3,855 subjects in 42 randomized trials, revealed that only the rotating-oscillating power toothbrushes reduced plaque and gingivitis to a greater extent than did manual toothbrushes. The reductions were modest, ranging from 6 percent according to the Löe and Silness gingival index1 to 17 percent according to the Ainamo-Bay bleeding-on-probing index.4
On the basis of these two systematic reviews in adults who were not orthodontic patients and the current systematic review in orthodontic patients, one may question whether power toothbrushes perform differently in general versus orthodontic populations. The findings of the reviews by Sicilia and colleagues2 and Robinson and colleagues3 suggest that some power toothbrushes, in particular the counter-rotational or rotating-oscillating types, demonstrate a modest benefit in the short term in the general population compared with manual toothbrushes.
The review by Kaklamanos and Kalfas revealed that investigators in only one of five randomized trials found power toothbrushes to be more effective than manual toothbrushes in patients receiving orthodontic treatment (most of whom were between the ages of 10 and 20 years). Orthodontic patients may respond differently from adult patients who are not undergoing orthodontic treatment because of their age, the presence of appliances and, thus, an altered oral environment.
TOP
Clinical question.
Review methods.
