The individual periodic control and maintenance program is an integral and critical part of restorative treatment, bringing tangible benefits to the patient and dentist. Patients will be able to have their problems diagnosed and corrected early or controlled to increase the longevity of their natural dentition or restorations. The dentist can anticipate possible complications and reinforce the patient’s confidence, minimizing the risk of misunderstandings or conflicts. Furthermore, a clinic focused on prevention will maintain a continuous flow of patients motivated and satisfied with their optimal state of oral health.

Control and maintenance program

The control and maintenance program should be an opportunity to strengthen the patient’s trust, reinforcing the purposes and benefits of the procedures. Ideally, the dentist responsible for the treatment should carry out this appointment, or at least part of it, because this professional knows the particularities of the patient and the clinical case. For the control and maintenance program to be effective in the long term, all procedures and observations must be documented in an organized manner on the patient’s Clinical Evolution Form. The following checklist is suggested to ensure that no critical data are forgotten:

• Update personal data.
• Update medical history.
• Update dental history.
• Clinical examination.
• Maintenance procedures.
• Preventive instructions.
• Control and maintenance report.

Update personal data: Changes to physical address, telephone numbers, or email addresses should be made by the receptionist.

Update medical history: The dentist should perform this at the beginning of each follow-up appointment based on questions such as: Have there been any changes in the condition of your health since the last visit? Are you under medical treatment? Have there been any changes to your prescribed medications?

Add the relevant data and explanations provided to the patient’s Clinical Evolution Form. The dentist should compare the present systemic diseases, treatments, or medications used with the patient’s oral health, risk factors, and oral care. The patient’s physician should be contacted in case of doubt.

Update dental history: The dentist should ascertain the degree of patient satisfaction or whether there are any concerns regarding previous treatment. Various reports of sensitivity, pain, or discomfort of any nature should be carefully investigated during the clinical examination.

Check the patient’s Clinical Evolution Form for observations regarding priority points to be reassessed. Notes regarding previous procedures should be considered to involve the patient in current needs and estimate future control and maintenance strategies. Some situations will need to be continuously monitored because not all findings can be fully resolved, either for reasons relating to the patient or due to treatment limitations. Untreated conditions and aspects with a reasonable or unfavorable prognosis of previous treatment, such as weakened teeth, endodontically treated teeth, or periodontally compromised teeth, should be reviewed through clinical and complementary examinations.

All this information should be detailed on the Clinical Evolution Form to serve as a reference to clarify potential problems. These notes should contain well-defined information such as “reevaluate tooth 26 with esthetically deficient restoration;” “reevaluate furcation in tooth 47;” “patient advised that if the sensitivity of tooth 14 persists, they should contact us immediately;” “patient emphatically encouraged to use the interocclusal splint but showing resistance, patient was warned of the risks;” etc [Figure 6-01].

[Figure 6-01] The maintenance phase is an integral part of treatment planning. Its elaboration will be associated with the risk factors, and it may change with the treatment’s evolution or with the patient’s individual responses.

Clinical examination: Based on the review of the data, a new clinical examination should be performed, paying particular attention to the patient’s risk factors that may now have changed.

QR linking to the Summary of the Diagnostic Evaluation and Preliminary Treatment Plan Form template that can be customized.

Individual patient risk analysis

The control and maintenance program should be fully linked to the individual risk analysis, carried out from the anamnesis and the initial clinical examination, and modified according to tissue changes as well as the patient’s behavioral changes throughout the treatment. The interval between maintenance appointments, their duration, and the procedures to be performed should be estimated to prevent, arrest, or control the evolution or recurrence of oral issues.

Thus, a control and maintenance program tailored to the needs of patients should consider the risk factors discussed below:

1. General patient factors: These refer to the patient’s characteristics obtained from the anamnesis and explored in depth during the treatment. They are related to the patient’s age, general health status, sleep quality, diet, habits, psychologic profile, socioeconomic status, time constraints, and motivation.

2. Esthetic factors: These are factors related to the patient’s esthetic concerns, demonstrated during the anamnesis and treatment. In most restorative treatments, these aspects are linked to the preservation of the esthetic results or some improvement in this condition that could not be achieved previously. The degradation of restorative materials, the interface between tooth and restoration, and the stability of the gingival tissue should be observed. Some restorative materials or their handling can be subject to stains or fractures and require maintenance with periodic polishing. Darkened roots can also be evident in gingival recession and cause patient dissatisfaction. Teeth or implants in areas with a thin gingival phenotype are a constant source of concern and should be monitored carefully.

Using visual inspection, observe the quality of the esthetic result concerning dentofacial integration and the exposure of interfaces and degradation of the restorative material. Ask whether there is anything that bothers the patient concerning esthetics.

3. Functional factors: These are primarily related to the functional diagnosis and the responses of the stomatognathic system to the treatment.

Question the degree of functional comfort or whether there is any concern, pain, or discomfort in the masticatory muscles or temporomandibular joints. Intraorally, investigate the presence of wear facets, chipping, or cracks on teeth or restorations. Assess the occlusal contacts (magnitude and distribution) on the teeth and on the interocclusal splint (when fabricated) with an articulating tape or electronic devices such as the T-Scan (TekScan, USA) or OccluSense (Bausch, Germany). Refine the necessary occlusal contacts and check the intensity of the interproximal contacts.

4. Structural factors: These are related to the structural integrity of teeth and restorations such as weakened teeth or questionable restorations that require constant monitoring. The presence of carious and noncarious lesions should be evaluated based on the patient’s risk profile. Structural wear should be monitored by visual observation, photographs, or intraoral scans. It is necessary to analyze whether the pattern of dental attrition is ongoing in the patient and to inform them about the presence of parafunctional habits that contribute to the progression of this wear.

A careful visual examination of the existing restorations is necessary to look for wear, cracks, chipping, or fractures. The marginal integrity and contours should also be checked with an explorer, complemented by periapical and interproximal radiographs.

Teeth or prostheses mobility should be checked. Fixed partial dentures, especially more extensive ones, have the risk of debonding and should be carefully and gently maneuvered with the thumb and index finger during this examination to exclude this possibility.

Finally, question and evaluate the degree of comfort of prostheses on implants in terms of their masticatory efficiency and food impaction. Their stability should be analyzed by checking for the loosening of screws, debonding of works, or mobility of the implants.

5. Biologic factors: These are related to the patient’s risk factors in terms of periodontal disease, peri-implant disease, gingival phenotype, areas of gingival recession, dentinal hypersensitivity, and standard of oral hygiene. Also, they relate to the maintenance of periapical lesions in posttreatment repair.

The periodontal status and response of the gingival tissue closely related to prostheses over teeth or implants should also be inspected for any signs of inflammation using a periodontal probe. Areas with bleeding on probing and periodontal pockets should receive preventive care, even in patients with no preexisting periodontal disease. Regions with the presence of suppuration will need immediate intervention to minimize tissue loss.

The standard of oral hygiene should be continually reassessed due to its influence on the longevity of teeth and restorations. Although the patient should already be aware of the importance of good oral hygiene, there may be fluctuations in motivation and generalized hygiene failures in specific areas. These areas should be pointed out and corrected.

Radiographic reevaluation

Radiographic reevaluation should complement the clinical examination and is of great diagnostic importance for correct decision making in the maintenance phase. In general, the type and interval of radiographs depend on the individual risk factors and the extent of the treatment. A complete radiographic examination should be performed at the end of treatment or at the first maintenance visit to provide reference and documentation. This conduct is even more critical in cases involving extensive treatment.

Patients with low caries risk should be evaluated with interproximal radiographs every 24 months, and high-risk patients every 6 to 12 months. Patients with low periodontal risk should be evaluated with full-mouth radiographs (14 periapical radiographs) every 24 months, and those with high caries risk every 12 months or less, depending on the professional’s judgment^1–3.

According to the American Dental Association (ADA)² guidelines, patients with various risk factors such as doubtful endodontic conditions, dental implants, or oral pathologies should be monitored radiographically, according to the clinical judgment of the professional.

This author proposes that endodontic follow-up should vary according to the specific diagnosis determined by the specialist. For treatments of vitalized teeth, radiographic control should be performed every 12 months. On the other hand, teeth with pulpal necrosis and reduced or absent periapical lesions on the radiographs should undergo radiographic control every 6 and 12 months. For teeth with pulpal necrosis, extensive damage on the radiographs, or in teeth that have undergone periapical surgery, an evaluation is recommended after 4 to 6 months of treatment to assess the initial repair, and then every 12 months. Endodontic control of all cases mentioned should be performed annually for a minimum of 5 years. The presence of any symptomatology should be evaluated together with the radiographic image. For this, cone beam computed tomography (CBCT) is currently preferable to conventional periapical radiographs for a more accurate diagnosis.

Dental implants should be evaluated with periapical radiographs every 12 months for the first 3 years. After this initial period, a radiographic evaluation every 18 to 24 months is recommended.

For cases of extensive restorative treatments, this author suggests a complete radiographic examination every 18 to 24 months, in addition to localized periapical radiographs in cases of specific concerns [Table 6-01].

[Table 6-01] Interval suggestions for performing radiographs according to the patient’s risk profile.

Source: Kim and Mupparapu1, ADA2, Stefanac and Nesbit³.

After performing the clinical and radiographic examination and when no clinical intervention is necessary, one should focus on maintenance procedures and guidelines for oral hygiene and habits, always following the individual risk assessment.

In the end, elaborate on a maintenance report containing the most relevant aspects observed and a summary of the recommendations given to the patient [Figure 6-02]. The patient should get a copy of this report, and another should be kept on their file. Scheduling a return date at this time is strongly indicated as it increases the patient’s commitment to the next appointment.

[Figure 6-02] Maintenance appointment report carried out by the team’s periodontist (Dr. Maria Cristina Moscatello). All essential data must be recorded and reevaluated.

Maintenance procedures

Biofilm control needs to be performed daily by the patient through oral hygiene, and periodically by the dentist during the control and maintenance program.

Oral hygiene devices used by the patient, such as toothbrushes, interdental brushes, dental floss/tape, and tongue scrapers, can mechanically disorganize the bacterial biofilm, preventing its growth. This is considered key to preventing tooth decay and gum disease. During maintenance appointments, the dentist will complement biofilm removal due to the limitations of the patient to control and remove dental calculus. Prophylaxis should be carried out methodically by quadrants. For this purpose, the professional can use several resources such as manual instrumentation with periodontal curettes, ultrasonic instrumentation, pressurized equipment, rubber cups, or prophylactic brushes with appropriate abrasive pastes. Clinical procedures should be performed with magnification as it considerably increases the quality of the work performed. The average appointment for control and maintenance takes 45 to 60 minutes (min), depending on the case complexity. The presence of deep periodontal pockets, irregular root anatomies, furcation areas, and a large number of restorations to be polished extend the appointment⁴.

As previously mentioned, the interval between maintenance appointments will depend on the patient’s risk assessment³. This interval should be adapted according to the control of risk factors and patient motivation regarding self-care.

Suggested intervals between maintenance appointments

Patients at high risk for dental caries or periodontal disease: 3 months.

Patients at low risk for dental caries or periodontal disease: 6 to 12 months.

Patients at high risk for tooth wear due to abrasion, attrition, or biocorrosion: 4 to 6 months while the etiologic factors are not controlled; 6 to 12 months after controlling for risk factors.

Patients undergoing extensive restorative treatments: Preliminary reassessment within 3 months; subsequent appointments according to the revised risk analysis at the end of each appointment, typically 6 to 12 months.

Patients with high functional risk: First evaluation within 3 months; if the patient does not report symptoms and the stomatognathic system is stable, the follow-up may be within 6 to 12 months; ask the patient to bring the stabilizing interocclusal splint (if they have one) to all appointments.

Dental calculus removal

Removal or scaling of dental calculus, supragingivally and subgingivally, can be performed manually with periodontal curettes and ultrasonic instrumentation. Ultrasound is practical and effective for supragingival procedures. It is usually well accepted by patients, except for those with gingival recession and root exposure, who tend to complain of sensitivity.

Within this sequence of procedures, manual instruments are limited to complementing the use of ultrasound in subgingival areas and those that are difficult to access as well as for root planing procedures. Ultrasonic devices produce vibrating oscillations in their metal parts that reach 50,000 Hz. These can remove the calculus by mechanical action and generate a phenomenon called “cavitation,” in which hydrodynamic shock waves and microflows of liquids in the vicinity of the instrument tip help to disorganize bacterial colonization and clean the area^5–9 [Figure 6-03].

[Figure 6-03] Ultrasonic devices are effective for removing calculus and stains on the tooth surface. However, they are contraindicated or should be used cautiously near the margins of composite resin or ceramic restorations.

Ultrasound is contraindicated or should be used cautiously near the margins of composite resin or ceramic restorations. In these cases, it is preferable to use delicate hand instruments, with movements parallel to the gingival margin, to avoid any risk of damaging the restorations¹⁰. The use of ultrasonic instrumentation with metal tips on the surface of implants is debatable due to the possibility of scratching the surface. However, some authors believe that the damage is minimal and outweighed by the benefits of removing the subgingival biofilm¹¹. Plastic curettes, suitable for cleaning the surface of implants, have been recommended to minimize surface damage [Figure 6-04].

[Figure 6-04] Plastic curettes are recommended for dental implants due to the low risk of damage to the implant surfaces.

In cases of absence of periodontal problems, perform supragingival scaling of all teeth by quadrants, starting with the maxillary right, followed by the maxillary left, mandibular left, and mandibular right. Although patients associate subgingival scaling with pain, 80% to 90% of these patients consider the procedure bearable, and the application of local anesthesia is limited to areas considered hypersensitive¹². In many cases, when there is discomfort, the procedure can be attempted with a topical anesthetic on the gingival margin.

Subgingival scaling for the treatment of periodontal pockets or furcation areas may require an additional appointment or referral to a specialist, depending on the extent of the periodontal disease.

Crown polishing

Crown polishing aims to remove bacterial biofilm and extrinsic stains from tooth surfaces and polishing areas previously treated by manual or ultrasonic instrumentation. For this purpose, pressurized jets, rubber cups, and brushes can be used.

Sodium bicarbonate jets should preferably be used on enamel areas and unrestored tooth surfaces. They are not indicated on composite resin surfaces and cementation lines due to their ability to cause volumetric loss and increase the surface roughness of the restorative material¹³. It is also necessary to consider that the grain size of sodium bicarbonate varies considerably, depending on the manufacturer. Glycine-based particle powder (Clinpro Prophy Powder; 3M, USA) is indicated for its lower potential for surface damage on dental implants and restorative materials and areas with root exposure. This product also has a more pleasant taste. Pressurized jets are very effective for prophylaxis of areas that are difficult to access by other methods such as regions under pontics in fixed partial dentures, gingival surfaces under implant-retained hybrid dentures, and orthodontic appliances [Figure 6-05].

[Figure 6-05] AquaCare is a pressurized device for cleaning the tooth surface with suitable abrasive substances.

Prophylaxis of free surfaces can also be performed using flexible rubber cups or Robinson brushes [Figure 6-06A,B] with abrasive prophylactic pastes. These rubber cups should be flexible and positioned perpendicular to the tooth surface, using low speed and light pressure [Figure 6-07A–D]. Currently, prophylactic pastes with different degrees of abrasiveness are available to be used sequentially, indicated according to the nature of the surface to be polished and the severity of the stain. Prophylactic pastes, such as CleanJoy (VOCO, Germany) [Figure 6-08] (RDA 16 [fine], 127 , or 195 [coarse]) and Proxyt (Ivoclar Vivadent, Liechtenstein) (RDA 7 [fine], 36 , or 83 [coarse]), have different colors for the different degrees of abrasiveness, facilitating identification and helping to clinically visualize the complete removal of a given paste before using the next one.

[Figure 6-06A,B] Rubber cups and brushes with varying shapes and stiffnesses should be selected accordingly. Thus, more rigid materials should be used in the supragingival regions, on enamel or ceramic surfaces, and in situations of more significant staining. More flexible materials should be used in intrasulcular areas on dentin and composite resin surfaces (DH Pro, Brazil).

[Figure 6-07A–D] Prophylactic or polishing pastes should be applied on the surfaces to be treated. Rubber cups or brushes should be positioned perpendicular to the tooth surface, with a speed of around 2,500 to 3,000 rpm and under light pressure.

[Figure 6-08] Prophylactic pastes with different degrees of abrasiveness are available for different situations. For example, red CleanJoy paste (coarse) has a relative dentin abrasivity (RDA) of 195 and high cleaning power. It is recommended for removing a significant amount of pigmentation and firmly adhered bacterial biofilm. The yellow paste (medium) has an RDA of 127, with a medium cleaning power. It removes a moderate amount of pigmentation and moderately adherent bacterial biofilm. The green paste (fine) has an RDA of 16 and is indicated for surface polishing, removing lightly adhered bacterial biofilm, and cleaning around implants. It should be used for the final polishing, after the red or yellow paste, or even after the bicarbonate jet.

Although it is recognized that the more abrasive the paste, the greater its cleaning capacity, selecting the one with the lowest possible abrasiveness is recommended. Thus, in these sequential systems, it is suggested to use a thicker paste for cleaning and a thinner one for polishing, avoiding unnecessary abrasion on the tooth’s surface or on the restorative material¹³.

Composite resin restorations can be polished with specific polishing pastes, such as aluminum oxide pastes (Enamelize; Cosmedent, USA), and with diamond pastes containing particles from 1 to 5 micrometers (μm) (Diamond Polish; Ultradent, USA, and Diamond Paste; Micerium, Italy) [Figure 6-09A–C].

[Figure 6-09A–C] Polishing pastes based on aluminum oxide (Enamelize; Cosmedent) or diamond particles (Diamond Polish; Ultradent, and Diamond Paste; Micerium) for use on restorative materials.

Rubber cups and Robinson brushes should be used at low speed, ideally around 2,500 to 3,000 rotations per min (rpm) on free tooth surfaces. Dental floss/tape dipped in these pastes, and fine aluminum oxide or diamond polishing strips, will complement the cleaning and polishing of the interproximal areas.

Cemented fixed prostheses should have their interproximal and pontic areas cleaned with interdental brushes or with the thick part of dental floss/tape that has this specific purpose such as Super Floss (Oral-B, USA) or Spongy Floss (Edel White, Switzerland) [Figure 6-10A–C]. Screw-retained implant prostheses should be removed periodically for a more thorough cleaning.

[Figure 6-10A–C] Interproximal areas and areas under the pontics [A] need to be cleaned with interdental brushes or the spongy part of floss that has this specific purpose such as Super Floss (Oral-B) [B] or Spongy Floss (Edel White) [C]. The patient should be instructed at this time about the correct hygiene in these areas.

Professional application of fluoride

Products containing fluoride at neutral pH are the safest for maintaining restorative treatments¹³. Acidulated phosphate fluoride (1.23%) can cause degradation of the filler particles and the bonding agents, increasing the surface roughness. Due to its acidic pH, this material can react with glass-ceramic components, causing corrosion and surface deterioration, removal of extrinsic characterizations, and changes in color and light reflection^10,14.

Varnishes with a high concentration of fluoride (5%) are effective against caries¹⁵ due to their ability to keep fluorides in contact with the tooth surface for several hours. Patients should avoid brushing their teeth until bedtime⁴.

Both neutral fluoride gel and fluoride varnish should be applied to exposed root surfaces after prophylaxis to reduce dentinal hypersensitivity that can occur after mechanical instrumentation, in addition to benefiting patients at high risk for caries or dental biocorrosion [Figure 6-11A–D].

[Figure 6-11A–D] Acidulated [A], neutral [B] fluoride gels or varnishes [C,D] can be used routinely in maintenance appointments. However, their use is particularly encouraged in those patients at high risk for caries or those with biocorrosion.

Oral hygiene instructions

Maintenance appointments should not be seen as isolated activities but as part of a long and mutually beneficial process. The oral hygiene instructions should be individualized, comprehensive, and readily accepted by the patient¹⁶.

Try not to overload the patient with information at first due to the difficulty of understanding it, the technical dexterity required, and the need for awareness and the change of habits¹³. Suggestions should be introduced gradually based on their benefits and for greater assimilation and motivation.

The bacterial biofilm is a structured ecosystem formed by bacteria in a matrix of polysaccharides, the outermost layers of which protect the innermost layers¹⁷. It firmly adheres to the tooth surface, and controlling it is required in most periodontal diseases, depending on their specificity. To a lesser extent, it is associated with dental caries, which are directly related to the patient’s diet.

The growth and organization of bacterial biofilm occur within hours in the oral environment, and it must be removed entirely at least once every 48 h to prevent gingival inflammation¹⁸. The ADA recommends that individuals brush their teeth at least twice a day and use dental floss/tape or any other interdental cleaning method once daily to remove biofilm and prevent gingivitis^19,20. The careful control of biofilm performed by the patient, combined with its periodic removal performed by the dentist, reduces the total amount of supragingival microorganisms in the periodontal pockets and furcation areas, significantly reducing the total amount of periodontal pathogens⁸.

The mechanical and chemical control of biofilm should occur and be encouraged from the first appointment. Oral hygiene should start with rinsing the mouth with water to remove possible food residues. Mechanical control includes using toothbrushes, interdental brushes, dental floss/tape, and tongue scrapers. Chemical inhibitors of biofilm and dental calculus in toothpaste and mouthwashes also play an essential role in microbial control²¹. The fluorides in toothpastes and mouthwashes are essential for controlling dental caries²². Irrigators for home use together with antimicrobial solutions also assist in the mechanical and chemical control of biofilm. Thus, the careful prescription of dentifrices, fluoride-containing solutions, and antimicrobials should be carried out according to the needs of the individual patient⁴.

The dentist should provide conditions of access and instructions so that the patient can perform oral hygiene. Biofilm control is effective for preventing gingival inflammation, but it is not enough to reduce the incidence of caries. The essential long-term measure for caries prevention is to brush the teeth at least twice a day with fluoride toothpaste (above 1,000 ppm fluoride) and use interdental devices such as dental floss/tape or brushes²³. In addition, sugar and acidic foods and drinks should not be frequency consumed¹⁷.

Toothbrushing

Toothbrushing involves removing and modifying the supragingival and subgingival biofilm with manual or electric toothbrushes^4,24. Toothbrushes vary in size, design, hardness, and arrangement of their bristles. Regarding hardness, toothbrushes are generally classified as extra-soft, soft, medium, and hard. The bristle diameter ranges from 0.2 to 0.4 mm. Although there is no confirmed distinction between the types of toothbrushes²¹, brushing the teeth with a hard-bristled brush using vigorous horizontal movements and abrasive toothpaste should be avoided as it can cause noncarious cervical lesions (NCCLs), gingival recession, and dental abrasion²⁵. Thus, it is preferable to prescribe soft and extra-soft brushes. Although the design of the brush is a matter of personal choice, small heads are indicated for reaching areas that are difficult to access, and wide and comfortable handles favor the grip [Figure 6-12]. Toothbrushes should be replaced periodically, at least every 3 or 4 months, and sooner if the bristles are altered.

[Figure 6-12] Soft toothbrushes are recommended by the author, especially those with extra-fine bristles. Small heads for better access and handles with good grip are also advantageous features.

Although it is not the purpose of this book to go into details about the various brushing techniques proposed^26–31, the Bass technique³² is effective for displacing the supragingival biofilm and for reaching the subgingival biofilm, from 1 to 1.5 mm^33,34, causing minimal trauma to the gingival margin. It consists of positioning the bristles on the gingival margin, introducing them into the gingival sulcus at an angle of 45 degrees with the long axis of the tooth, and also in the interdental embrasures. Gentle pressure is applied with short back-and-forth movements without unseating the bristle tips. A sweeping motion is then made in the occlusal direction without rotating the toothbrush head [Figure 6-13A,B].

[Figure 6-13A,B] The Bass technique consists of positioning the bristles on the gingival margin, introducing them into the gingival sulcus at an angle of 45 degrees with the long axis of the tooth, and also in the interdental embrasures. Gentle pressure is applied with short back-and-forth movements without displacing the bristles. A sweeping motion is then made in the occlusal direction without rotating the brush.

Brushing should be carried out in an orderly and sequential manner to reach all the buccal, lingual, and occlusal surfaces. It should be complemented in the interproximal region with dental floss/tape or with interdental brushes. There is no exact brushing time, as it depends on the technique, the patient’s ability, the type of toothbrush, and the force exerted, among other things. In general, this process requires approximately 3 to 4 min. It is necessary to be aware of the patient’s difficulties regarding the brushing technique in order to motivate and instruct them to avoid traumatic horizontal movements.

Today’s electric toothbrushes feature a variety of bristle movements such as rotation, oscillation, vibration, or a combination of these. Some even add low-frequency sonic energy that generates a dynamic movement of fluids to increase the cleaning power³⁵ [Figure 6-14]. Studies have shown a slightly higher efficiency, around 11%, in removing bacterial biofilm with these devices, although the long-term benefits have not been established³⁶. In a systematic review, Robinson et al^36,37 concluded that using electric toothbrushes with rotation–oscillation movements was slightly superior to manual toothbrushes in removing dental biofilm and reducing gingivitis. This study also showed that electric toothbrushes with other types of movement performed similarly to manual toothbrushes.

[Figure 6-14] Electric toothbrushes are effective and should be used mainly by individuals who have difficulty performing the recommended manual technique or for those who have motor difficulties.

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