Powered vs manual tooth brushing in patients with fixed orthodontic appliances: A systematic review and meta-analysis


The objective of this systematic review and meta-analysis was to compare powered and manual toothbrushes for oral hygiene maintenance in orthodontic patients.


Electronic databases, including MEDLINE, Scopus, Google scholar, PubMed, Web of Science, the Cochrane Oral Health Group’s Trials Register, and CENTRAL, were searched without language restrictions. Randomized clinical trials directly comparing manual and powered toothbrushing including patients with fixed orthodontic appliances reporting predefined outcomes with a follow-up period of at least 4 weeks were included. Using predefined data extraction forms, 2 authors independently undertook data extraction with conflict resolution by the third author. Quality assessment was based on the Cochrane Risk of Bias tool, and overall evidence base was assessed using the Grading of Recommendations Assessment, Development and Evaluation system. A random effects meta-analysis combined the treatment effects across studies.


Five trials were considered appropriate for inclusion in the meta-analysis with 8 trials excluded. There are slight differences in plaque index reduction of 0.05 (−0.04, 0.13) and 0.11 (−0.10, 0.33) at 4 week and 8 week follow up, respectively, favoring manual toothbrushing, but this was not statistically significant. There are slight differences in gingival index reduction of −0.02 (−0.06, 0.02) and −0.01 (−0.05, 0.02) at 4 week and 8 week follow up, respectively, favoring powered brushing, but again, this was not statistically significant. The overall quality of evidence was very low to moderate for the primary outcomes.


Using manual or powered tooth brushing with fixed orthodontic appliances does not reduce plaque or gingival indexes at 4 weeks and 8 weeks. This conclusion is, however, based on low quality of evidence from few studies. Greater standardization of the methodology used is desirable in future trials to increase our confidence in these findings.


  • Powered and manual toothbrushes for fixed orthodontic patients were compared.

  • Data sources included mainly electronic databases.

  • Only 5 trials were considered appropriate for inclusion in a meta-analysis.

  • Plaque and gingival index reductions at 4 weeks and 8 weeks were not affected by brush type.

  • Further high-quality research is required to improve the reliability of the evidence.

The placement of fixed appliances not only encourages biofilm formation but also raises the level of acidogenic bacteria inside the biofilm. If patients do not maintain good oral hygiene during orthodontic treatment, the dental biofilm will produce acids that lead to enamel demineralization and white spot lesions around the orthodontic appliance. Development of the biofilm is also related to the presence of gingivitis, and the greater the accumulation, the higher the gingival bleeding index. , Because of the unpredictable nature of periodontal disease progression, orthodontic patients with gingivitis must be considered to be at risk of periodontal damage.

The presence of fixed orthodontic appliances also modifies the microbial environment increasing the proliferation of the facultative bacterial population. Orthodontic treatment can therefore affect periodontal health, compromising oral health in general. , Direct damage to the periodontium as a result of excessively extended orthodontic bands can lead to loss of attachment, causing gingival recession.

Clinically observed effects after placement of orthodontic appliances include inflammatory hyperplasia, gingival recession, and irreversible loss of attachment. These local factors further lead to biofilm accumulation and increase the risks of related problems during orthodontic treatment. The best way to avoid these deleterious effects is to prevent or control biofilm buildup. Maintaining good oral hygiene by toothbrushing is the main factor during this process, and regular toothbrushing, independent of educational level or social status, is a significant factor in oral health. , Effective toothbrushing depends on several factors including motivation, knowledge, and manual dexterity.

Powered toothbrushes were first introduced commercially in the early 1960s and have become established as an alternative to manual toothbrushing. There are many factors affecting the effectiveness of powered toothbrushing, from brush filament type and filament shape, size, orientation, and flexibility to the brush head size and shape and the presence or absence of a timer. As well as the rotational motion or oscillation of the brush head, newer powered brushes have multimotion actions that can also move in and out toward the tooth surface. Finally, battery type and duration influences brushing efficiency. All of these factors are important and must be kept in mind when selecting or assessing a powered toothbrush.

This systematic review aims to compare manual and powered toothbrushing during fixed orthodontic appliance treatment with regards to the removal of plaque, the health of the gingivae, and patient experience.

Material and methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for this systematic review and meta-analysis. , The eligibility criteria (PICOT) for this systematic review were as follows:

Population: patients undergoing fixed appliance orthodontic treatment.

Intervention: manual toothbrushing as a method of plaque control.

Comparison: powered toothbrushing as a method of plaque control.

Outcomes: plaque and/or gingival indexes, patient compliance, and patient experience.

Type of study: prospective randomized clinical trials (RCTs).

The following detailed selection criteria were applied for the review:

  • 1.

    Types of participants. We included patients wearing fixed orthodontic appliances, of any age with no reported disability that might affect toothbrushing ability.

  • 2.

    Types of interventions. Included in the review were all types of manual and powered toothbrushes. Trials in which participants were permitted to continue with their usual adjuncts to oral hygiene, such as flossing, were included. Trials of ≥28 days (4 weeks) were eligible and a subgroup analysis was carried out on the duration of intervention for the different outcome measures.

  • 3.

    Types of outcome measures. The primary outcome measures used plaque and/or gingival indexes. Secondary outcome measures were patient compliance and/or experience.

  • 4.

    Types of studies This review is confined to randomized controlled trials comparing manual and powered toothbrushes during fixed orthodontic treatment. It excludes trials only comparing different powered toothbrushes or those only comparing different manual toothbrushes.

Exclusion criteria

Cross-over and split-mouth trials were excluded. With cross-over trials there may be carry-over effects for the different toothbrushes on gingivitis due to the short time between the measurements. Split-mouth trials were not considered an appropriate design because they were not representative of “everyday use,” the effect of change of participant hand-use, and the risk of cross-over effects.

Studies were included irrespective of publication status or language as long as they could be translated. Toothbrushing studies in which the toothbrushing was combined with the use of mouth rinse or irrigation as part of the study intervention was excluded because of the risk of confounding.

Electronic database search

Data sources were the electronic databases MEDLINE, Scopus, Google Scholar, PubMed, Web of Science, the Cochrane Oral Health Group’s Trials Register, and CENTRAL, without language restrictions. Unpublished trials were searched for on www.ClinicalTrials.gov , the National Research Register, and Pro-Quest Dissertation Abstracts and Thesis database. Reference lists of the included studies were manually searched for any additional relevant publications. Authors were contacted when necessary for further information. Search terms for Medline via EBSCO were ((MESH “Orthodontics+” OR “plaque control” OR “manual brushing”) AND MH “powered brushing+” AND (“Plaque index” OR MH “gingival index+” OR “Patient experience”)). The search was initially run in April 2017 and updated in December 2018 and December 2019.

Using predefined data extraction forms, 2 authors (M.E., B.M.) independently undertook data extraction with any conflict resolution by a third author when necessary. Randomized clinical trial quality assessment was based on the Cochrane Risk of Bias tool. Trial quality was evaluated by assessing the domains of random sequence generation, allocation concealment, blinding of participants and personnel, blinding of assessors, incomplete outcome data, selective reporting of outcomes, and other potential sources of bias. Meta-analysis was planned to obtain a better understanding of the intervention effect. Mean difference and 95% confidence interval were calculated to express the comparative treatment effect. A random effects model meta-analysis was undertaken using RevMan software to combine treatment effects across studies for each outcome.

Data extraction process

The following information and details were extracted from each article, and transferred to customized data extraction forms: title, author name, author email and address, trial design, setting, funding source, sequence generation, allocation sequence concealment, blinding of participants and personnel, outcome assessor blinding, inclusion and exclusion criteria, total study duration, number of participants, age, sex, sample size calculation, type of treatment, intervention, comparisons, measurement tools or methods used, validity of methods, statistical analysis, outcomes (primary and secondary), results, and notes. Data extracted are summarized in Table I .

Table I
Summary of characteristics of studies included in systematic review
Author, year Sample size Age, y Gender Study duration, wk Number of groups Intervention Outcome Measuring tool Statistical difference
Hickman et al, 2002 63
(3 dropouts)
±15 35 F
28 M
8 G1 = powered
G2 = manual
Powered (orthodontic head brush)
Manual tooth brush
No difference in GI or PI
Eastman-bleeding-index is less in manual group
Modified PI
Eastman-interdental bleeding index
Tissue trauma
PI = no sig diff
GI = no sig diff
Interdental = sig diff for manual brush
Clerehugh et al, 1998 84
(5 dropouts)
up to 20 37 M
47 F
8 G1 = powered
G2 = manual
Braun Plaque Remover with OD 5 head vs Reach medium compact head, 2 min twice daily. Timer used
Manual tooth brush
G1 = SD in Plaque 37% and in interdental bleeding 12%
G2 = only in plaque 29%
No difference in bleeding
Modified PI
Eastman-interdental bleeding index
G1 = sig diff in PI and in interdental bleeding
G2 = sig diff in PI
Silvestrini Biavati et al, 2010 20 10-14 12 F
8 M
8 G1 = powered
G2 = manual
Oral B Professional Care 8500 electric toothbrush
Manual tooth brush
Group A electric toothbrush, were found to have a greater positive variation in plaque and bleeding gum indexes with respect to those in Group B, who were provided with a manual toothbrush. PI
Hypertrophy (present or absent)
Sig diff in both PI and GBI
Marini et al, 2014 66
(6 dropouts)
13-16 31 F
29 M
20 E1 = powered rotation-oscillation with OHI
E2 = powered rotation-oscillation only
M1 = manual with OHI
M2 = manual only
Electric toothbrush with or without OHI
Manual tooth brush with or without OHI
OHI is a factor in reducing PI % PI At T8, the PI scores of group E1 were lower than those of group E2; at T12, T16, and T20, PI of groups M1 and E1 were lower, respectively, to PI of groups M2 and E2
Sharma et al, 2015 60 12-32 26 M
34 F
8 G1 = manual (ortho brush)
G2 = powered
G3 = sonic powered
Electric toothbrush Sonic electric toothbrush
Manual tooth brush (orthodontic type)
Powered reduced PI %
Sonic reduced PI, GI, and interdental index
Eastman-interdental bleeding index
G3 – a sig diff reduction in PI, GI, and Eastman interdental bleeding index scores was found from baseline to 4 wk and from baseline to 8 wk
Ousehal et al, 2011 84 19.41 21 M
63 F
4 G1 = manual toothbrush, control group;
G2 = powered toothbrush;
G3 = manual toothbrush combined with a mouth rinse
Electric toothbrush
Manual tooth brush
Manual toothbrush and mouthwash
No diff in GI between 3 groups
G2 PI different from the 2 manual groups
Sig diff in PI between manual and electric brushes
Pucher et al, 1999 60
(8 dropouts)
23 M
29 F
6 G1 = inactive ionic battery toothbrush
G2 = active ionic battery toothbrush
Inactive electric toothbrush
Active toothbrush
G2: active battery, had lower PI at 3 time intervals GI
No sig diff in PI or GI
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Jan 9, 2021 | Posted by in Orthodontics | Comments Off on Powered vs manual tooth brushing in patients with fixed orthodontic appliances: A systematic review and meta-analysis
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