Introduction
Although powered toothbrushes have been reported to reduce gingivitis more than manual toothbrushes in the general population, the evidence regarding orthodontic patients has been inconclusive. Thus, we aimed to compare their effectiveness in relation to any available parameter regarding oral health in orthodontic patients with fixed appliances.
Methods
Searches without restrictions for published and unpublished literature and hand searching took place up to August 2017. Oral-health relevant data from randomized controlled trials of at least 4-weeks duration comparing powered and manual tooth brushing without supervision were reviewed. Data were classified as short term (assessments at 1-3 months) and long term (assessments at >3 months), and the random-effects method was used to combine treatment effects. Individual study risk of bias was assessed using the Cochrane Risk of Bias Tool, and the quality of evidence was evaluated according to the Grades of Recommendation, Assessment, Development and Evaluation approach.
Results
The initially identified articles were finally reduced to 9 randomized controlled trials investigating the periodontal health in 434 patients. Eight studies followed patients up to 3 months, and 1 up to 12 months during treatment. One study was at low and the rest at unclear risk of bias. Overall, in the short term, there was low-quality evidence that powered toothbrushes provide a statistically significant benefit compared with manual brushing with regard to the gingival index (weighted mean difference, −0.079; 95% confidence interval, −0.146 to −0.012; P = 0.021) and indexes assessing gingival bleeding (standardized mean difference, −0.637; 95% confidence interval, −1.092 to −0.183; P = 0.006). In the long term, only 1 available study showed a statistically significant benefit of powered over manual toothbrushes with regard to gingival index and bleeding. No differences were observed in probing pocket depth and relative attachment loss. For the rotation-oscillation brushes that involved the greatest body of evidence, statistically significant reductions in gingival index and bleeding were demonstrated only in the long-term study. No included study provided quantified measurements regarding caries activity.
Conclusions
Overall, powered toothbrushes may promote gingival health better than manual toothbrushes in orthodontic patients. However, no type demonstrated clear superiority. Better study standardization and reporting in longer follow-up studies are necessary to elucidate the clinical relevance of these results.
Highlights
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Powered toothbrushes may promote gingival health better than manual in orthodontic patients.
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No toothbrush type demonstrated clear superiority for gingival health.
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Better study standardization and reporting in longer follow-ups are necessary.
The risk of enamel decalcification and damage to periodontal supporting tissues are long recognized as problems during orthodontic treatment and remain major concerns, especially in patients with fixed orthodontic appliances. Fixed appliances encourage oral biofilm accumulation, since bands, brackets, orthodontic wires, and accessories act as plaque traps. Moreover, meticulous toothbrushing and interproximal care become much more difficult and time-consuming processes requiring skill and manual dexterity to complete efficiently. Thus, the presence of fixed appliances increases biofilm retention, and an ecologic shift to periopathogenic oral flora may occur, recognizable clinically as deterioration in periodontal clinical parameters. Furthermore, under certain conditions, a cariogenic environment may develop, and enamel decalcification can also be observed.
In this respect, attainment and maintenance of effective daily oral hygiene practices, periodic instruction and motivation, and monitoring of dental and periodontal statuses throughout treatment are critical elements for oral tissue health and overall success of orthodontic treatment. Specifically, the mechanical removal of microbial biofilm is essential in maintaining the microbial ecosystem in equilibrium with healthy tissues. The primary means of mechanical biofilm control are toothbrushes, complemented by interdental cleaning aids, and secondarily by other devices such as oral irrigators, chewing sticks, and so on.
With regard to powered toothbrushes, a recent Cochrane Collaboration systematic review suggested that, in the general population, certain types of these devices are more effective in reducing oral biofilm and preventing gingivitis than manual toothbrushes, in both the short and long terms. However, this review did not focus specifically on orthodontic patients. Concerning patients with fixed orthodontic appliances, quantitative data synthesis of the then-available data to Kaklamanos and Kalfas suggested that the relevant information was insufficient to draw robust conclusions regarding their comparative advantages and that any inferences for clinical practice were precluded. They also suggested the need for future trials with a standardized methodology to increase the relevance to the clinical situation under investigation. However, after that publication, the effectiveness of powered compared with manual toothbrushes in orthodontic patients has not been investigated in an evidence-based manner.
The objective of this systematic review was to systematically investigate and appraise the quality of the most up-to-date evidence regarding the effectiveness of powered toothbrushes compared with manual ones in maintaining oral tissue health during orthodontic treatment.
Material and methods
Protocol and registration
This review was based on a specific protocol developed and piloted following the guidelines outlined in the PRISMA-P statement and registered in PROSPERO (CRD42015027997). Furthermore, conduct and reporting followed the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA statement, respectively.
Eligibility criteria
The eligibility criteria were based on the PICOS (participants, intervention, comparison, outcomes, study design) acronym. We included randomized controlled trials of at least 4-weeks duration comparing powered and manual toothbrushing without supervision as part of normal everyday oral hygiene procedures. Thus, split-mouth studies were excluded. Animal studies, noncomparative studies (case reports and case series), systematic reviews, and meta-analyses were also excluded ( Supplementary Table I ).
Information sources, search strategy and study selection
Overall, 8 databases were searched up to August 2017. One author (S.A.A.M.) developed detailed search strategies for each database. They were based on the strategy developed for MEDLINE but revised appropriately for each database to take account of the differences in controlled vocabulary and syntax rules ( Supplementary Table II ).
No restrictions were placed on language, date, and status of publication. In addition, efforts to obtain additional and ongoing trials were made, and the reference lists of all eligible studies and relevant reviews were searched.
Two authors (S.A.A.M. and E.G.K.) assessed the retrieved records for inclusion independently. They were not blinded to the identity of the authors, institutions, or results of the research. Subsequently, they obtained and assessed, again independently, the full report of records considered by either reviewer to meet the inclusion criteria. Disagreements were resolved by discussion or consultation with the third author (A.E.A.).
Data collection and data items
The same 2 authors performed data extraction independently, and any disagreements were again resolved by discussion or consultation with the third author. Predetermined and prepiloted data collection forms were used to record the desired information ( Supplementary Table I ).
The eligible studies were considered to be “short term” if the experimental period was up to 3 months and “long term” beyond that period. The mode of action of the powered toothbrushes was categorized according to the study of Kaklamanos and Kalfas. Data on gingivitis were extracted in the form of indexes recording qualitative changes in the gingivae and assessing gingival bleeding (absence or presence based on scoring criteria) ( Supplementary Table I ). When a study recorded outcomes at various time points, only the latest measurements were extracted. Only when a study falling under the “long-term” category included measurements that could be analyzed within the “short-term” data category was information from 2 time points noted. If we needed clarifications on the published data or additional material, attempts to contact the corresponding authors were made.
Risk of bias in individual studies
Two authors (S.A.A.M. and E.G.K.) assessed the risk of bias in individual studies, independently and in duplicate, using the Cochrane Collaboration’s Risk of Bias assessment tool for randomized controlled trials and approach. Any disagreements were resolved by discussion or consultation with the third author (A.E.A.).
Summary measures and approach to synthesis
From the retrieved publications, data from different indexes that measured, with high correlation, the same concept on different scales were extracted. Thus, to enable quantitative synthesis, the effects of the interventions for continuous outcomes were expressed as standardized values (standardized mean differences with relevant 95% confidence intervals [CI]). Where, in a particular comparison, only 1 index was recorded, the intervention effect was expressed as the weighted mean difference together with the 95% CI. For dichotomous outcomes, the effects of interventions were expressed as relative risk with the 95% CI.
The random-effects method for meta-analysis was used to combine data from studies that reported similar measurements in appropriate statistical forms, since they were expected to differ across studies due to clinical diversity in terms of participant and intervention characteristics. A combination of parallel and crossover trials was planned according the principles outlined by Elbourne et al. When the statistical reporting of crossover trials lacked important information, the corresponding author was contacted for the necessary clarification. In case of synthesis of 3 or more trials, 95% prediction intervals were calculated to predict treatment effects in future trial settings. To identify the presence and extent of between-study heterogeneity, the overlap of the 95% CIs for the results of individual studies was inspected graphically, and the I 2 statistic was calculated.
All analyses were performed with comprehensive meta-analysis software (version 2.2.04; BioStat Solutions, Englewood, NJ). Significance (α) was set at 0.05, except for 0.10 used for the heterogeneity tests.
Risk of bias across studies and additional analyses
If a sufficient number of studies were identified, analyses were planned for small-study effect and publication bias. If deemed possible, exploratory subgroup analyses were planned according to participant and intervention characteristics.
In addition, the quality of evidence at the longest follow-up available for key outcomes was assessed based on the grades of recommendation, assessment, development, and evaluation (GRADE) approach.
Results
Study selection and characteristics
The flow of records through the reviewing process is shown in Figure 1 . Initially, 1505 references were identified, 463 were excluded as duplicates, and 1005 more were excluded on the basis of their title and abstract. From the 37 records that remained, 10 studies were excluded because they were not randomized, 5 because they presented only data on plaque, 1 due to an inadequate follow-up period, and 3 more because they combined the use of the toothbrushes with other interventions. Moreover, we excluded 5 crossover trials with inadequate washout periods and 4 with inadequate statistical information. Finally, 9 full-text trial reports were included in this systematic review.
The characteristics of these studies are presented in Tables I and II . The articles were published between 1997 and 2015; the authors had recruited 434 patients and investigated periodontal health. No study provided quantified measurements regarding caries activity. Of the 9 trials, 6 involved a rotation-oscillation action toothbrush, 1 a side-to-side action toothbrush, 1 an ionic toothbrush, 1 a toothbrush with bristles pulsating at a frequency of 6000 strokes per minute, and another investigated 2 powered toothbrushes, 1 with an oscillating head and 1 that was sonic.
| Study | Intervention characteristics | Included outcomes | Additional information |
|---|---|---|---|
| Clerehugh et al (1998) United Kingdom RCT (parallel, single blind) Duration: 8 weeks |
Group 1: Braun Oral-B Plaque Remover (D5) + orthodontic brush head Group 2: Reach Compact Head Medium Oral hygiene: Oral hygiene instructions at the beginning, printed handout, brushing for 2 min, twice a day with fluoride dentifrice, use of 0.05% sodium fluoride solution. Timing brushing with either the built-in electronic timer or a timer. Recommendations: no use of antibiotics |
LSGI, EIBI, safety assessments (doctor assesses trauma on soft/hard tissues and appliances) Assessment: baseline, 2 mo (patients allowed to brush in the morning and under supervision before measurements; thus, plaque measurements were not considered; full-mouth recordings). |
A priori sample calculation: yes Examination reliability: NR, but the examiners “had considerable experience” Compliance monitoring: toothbrushing diary |
| Hickman et al (2002) United Kingdom RCT (parallel, single blind) Duration: 8 weeks |
Group 1: Braun Oral-B Plaque Remover (D5) + orthodontic brush head Group 2: Reach Compact Head Medium Oral hygiene: oral hygiene instructions at the beginning of the trial, printed handout, brushing for at least twice a day with fluoride dentifrice, use of fluoride solution. Timing brushing with either the built-in electronic timer or a timer. Recommendations: no use of interdental brushes |
LSGI, EIBI, safety assessments (trauma on tissues) Assessment: baseline, 2 mo (patients brushed after breakfast as normal; full-mouth recordings) |
A priori sample calculation: yes Examination reliability: NR Compliance monitoring: toothbrushing diary |
| Ho and Niederman (1997) United States RCT (parallel, single blind) Duration: 4 weeks |
Group 1: Sonicare sonic toothbrush Group 2: Oral-B P35 toothbrush Oral hygiene: oral hygiene instructions, brushing for 2 min, twice a day with fluoride dentifrice. Timing brushing with either the built-in electronic timer or a clock. |
LSGI, BOP, pocket depth Assessment: baseline, 1 mo (no instructions on brushing before measurements; full-mouth recordings) |
A priori sample calculation: NR Examination reliability: NR Compliance monitoring: NR |
| Park et al. (2004) Korea RCT (parallel, single blind) Duration: 8 weeks |
Group 1: Braun Oral-B Plaque Control D9511 + Ortho brush head Group 2: Butler G.U.M. 124 Oral hygiene: oral hygiene instructions at the beginning of trial, brushing at least twice a day for 2 min, change bristles every 4 weeks |
LSGI, SBI Assessment: baseline, 2 mo Full mouth recordings |
A priori sample calculation: NR Examination reliability: NR Compliance monitoring: NR |
| Park et al. (2005) Korea RCT (parallel, single blind) Duration: 12 months |
Group 1: Braun Oral-B Plaque Control + Ortho OD15-1 brush head Group 2: Butler G.U.M. 124 Oral hygiene: oral hygiene instructions at the beginning of trial, brushing at least twice a day for 2 min |
LSGI, ABGBI, pocket depth, relative attachment loss Assessment: baseline, 12 mo Full mouth recordings |
A priori sample calculation: NR Examination reliability: NR Compliance monitoring: NR |
| Pucher et al (1999) United States RCT (parallel, double blind) Duration: 6 weeks |
Group 1: Hukuba ionic toothbrush (active battery) Group 2: Hukuba ionic toothbrush (inactive battery) Oral hygiene: oral hygiene instructions at the beginning of trial, brushing at least twice a day for a minimum of 2 min with stabilized stannous fluoride (0.4%) toothpaste. Recommendations: not having an oral prophylaxis |
LSGI, safety assessments (doctor assesses trauma on soft/hard tissues; patients asked about any adverse reactions) Assessment: Baseline, 6 wK (patients asked not to brush for 12 h before the initial measurement and brushing afterward; only data from recordings before brushing were used; full-mouth recordings) |
A priori sample calculation: NR Examination reliability: NR Compliance monitoring: verified verbally and the toothbrush heads were examined for wear |
| Sharma et al (2015) India RCT (parallel, single blind) Duration: 8 weeks |
Group 1: Colgate 360° whole mouth clean Group 2: Colgate 360° sonic power Group 3: Colgate Ortho Oral hygiene: oral hygiene instructions at the beginning of trial, brushing at least twice a day, printed instructions, timer Recommendations: not having an oral prophylaxis, no flossing or mouthwash use during the study |
LSGI, EIBI, safety assessments (patients asked if they experienced any soft or hard-tissue trauma from brushing with the allocated brush) Assessment: baseline, 2 mo (no mention of whether patients were allowed to brush before measurements; labial or buccal surfaces of teeth measured) |
A priori sample calculation: NR Examination reliability: NR but mentioned that patients were examined by 1 examiner to minimize interexaminer bias Compliance monitoring: NR |
| Silvestrini Biavati et al. (2010) Italy RCT (parallel, single blind) Duration: 8 weeks |
Group 1: Oral B Professional Care 850 Group 2: Oral B Ortho P35 Oral hygiene: Oral hygiene instructions at the beginning of trial, reinforced at 2 weeks, printed handout, brushing at least twice a day Recommendations: not having an oral prophylaxis, no flossing or mouthwash use during the study |
ABGBI, gingival hypertrophy Assessment: baseline, 2 mo (no mention of whether patients were allowed to brush before measurements; no clear information on sites recorded) |
A priori sample calculation: NR Examination reliability: NR Compliance monitoring: NR |
| Singh (1999) United States RCT (parallel, single blind) Duration: 60 days |
Group 1: Butler Pulse Plaque Remover, Group 2: Oral-B P35 toothbrush Oral hygiene: oral hygiene instructions at the beginning of trial, brushing for 2 min Recommendations: not having an oral prophylaxis |
LSGI, PBS, safety assessments (doctor assesses trauma on soft tissues) Assessment: baseline, 2 mo (patients not allowed to brush 12-24 hours before measurements; postbrushing measurements were not considered; full-mouth recordings) |
A priori sample calculation: NR Examination reliability: investigated Compliance monitoring: toothbrushing diary |
| Study | Inclusion and exclusion criteria | Patients included and analyzed (n) |
|---|---|---|
| Clerehugh et al (1998) |
Inclusion criteria: 10-20 years old, edgewise fixed orthodontic appliance therapy simultaneously in both arches, brushing at least once a day, mean plaque score >1.25, gingival bleeding >30% of sites, in good general health Exclusion criteria: medical contraindications, mental or physical handicaps compromising manual dexterity, poor compliance, poor periodontal health, gross or uncontrolled caries, oral prophylaxis in the previous 4 weeks, use of antibacterial mouth rinses |
84 subjects (37 M, 47 F) (78 patients, <16 years old) Group 1: 41 randomized (37 analyzed) Group 2: 43 randomized (42 analyzed) |
| Hickman et al (2002) |
Inclusion criteria: 10-20 years old, edgewise fixed orthodontic appliance therapy simultaneously in both arches, brushing at least once a day, gingival bleeding >20% of sites, in good general health Exclusion criteria: medical contraindications, poor manual dexterity, poor compliance, poor periodontal health, active caries, oral prophylaxis in previous 4 weeks, use of antibacterial mouth rinses, current use of a powered toothbrush |
63 subjects (28 M, 35 F) Group 1: 33 randomized [age ( x ¯ ±SD): 14.9 ± 1.4] (15 M, 18 F) (31 analyzed) Group 2: 30 randomized [age (x ± SD): 15.4 ± 2.1] (13 M, 17 F) (29 analyzed) |
| Ho and Niederman (1997) |
Inclusion criteria: 11-18 years old, fixed orthodontic appliance therapy simultaneously in both arches, LSGI >2 Exclusion criteria: no medical or physical problems impeding or compromising study participation, no intake of antibiotics, steroids, or nonsteroidal anti-inflammatory drugs |
24 subjects (12 M, 12 F) Group 1: 12 randomized [age ( x ¯ ) ≈ 15] (6 M, 6 F) (analysis unclear) Group 2: 12 randomized [age ( x ¯ ) ≈ 15] (6 M, 6 F) (analysis unclear) |
| Park et al (2004) |
Inclusion criteria: medically healthy patients of the orthodontic clinic, having edgewise orthodontic appliances Exclusion criteria: pregnancy; antibiotic use |
34 subjects (15 M [age ( x ¯ ±SD): 18.8 ± 4.3], 19 F [age: 16.2 ± 4.1]) Group 1: 17 randomized (17 analyzed) Group 2: 17 randomized (15 analyzed) |
| Park et al (2005) |
Inclusion criteria: medically healthy, treatment with fixed orthodontic appliances Exclusion criteria: pregnancy, severe periodontal problem, antibiotic use |
40 subjects [age ( x ¯ ±SD): 19.8 ± 4.3] Group 1: 20 randomized (20 analyzed) Group 2: 20 randomized (20 analyzed) |
| Pucher et al (1999) |
Inclusion criteria: older than 12 y, minimum of 20 teeth Exclusion criteria: no taking of medications affecting plaque formation and no antibiotic use 3 months before the study or during the study |
60 subjects Group 1: 30 randomized (27 analyzed; 11 M, 16 F; age ( x ¯ ±SD): 13.89 ± 1.58) Group 1: 30 randomized (25 analyzed; 12 M, 13 F; age ( x ¯ ±SD): 15.96 ± 3.69) |
| Sharma et al (2015) |
Inclusion criteria: patients who were to receive fixed orthodontic treatment with maxillary and mandibular preadjusted edgewise appliance therapy simultaneously, at least 20 teeth present, minimum of 16 brackets or bands on teeth, brushing habit of at least once per day, age13-32 years, no use of antibiotics in the past 2 months, absence of menstruation or pregnancy at the time of recording scores. Exclusion criteria: systemic disease, use of antibiotics, steroids, or nonsteroidal anti-inflammatory drugs within past 2 months or during the study, fewer than 5 teeth per quadrant, immunosuppressant drugs, medically compromised, mentally handicapped subjects, subjects with poor manual dexterity, poor compliance, subjects who received oral hygiene instructions from dental professional in past 6 months, severe gingival inflammation, no obvious periodontal disease (systemic or local) or attachment loss or pocketing, use of antibacterial mouth rinses, juvenile/aggressive periodontitis, previous or current use of powered or manual orthodontic toothbrushes, gross caries lesions, diagnosed with early onset periodontitis, smoking, tobacco products, pregnancy, acute illness |
60 subjects Group 1: 20 randomized (6 M, 4 F) [age ( x ¯ ): 20.6] Group 2: 20 randomized (2 M, 8 F) [age ( x ¯ ): 19.25] Group 3: 20 randomized (6 M, 14 F) [age ( x ¯ ): 17.9] |
| Silvestrini Biavati et al (2015) |
Inclusion criteria: permanent dentition, age less than 16 years Exclusion criteria: NR |
20 subjects (8 M, 12 F) [age ( x ¯ ): 11.4] Group 1: 10 randomized (6 M, 4 F) (10 analyzed) Group 2: 10 randomized (2 M, 8 F) (10 analyzed) |
| Singh (1999) |
Inclusion criteria: 11-19 years, minimum of 20 teeth, generalized to moderate gingivitis, in good health, band and brackets bonded for at least 6 weeks, bands and brackets on a minimum of 16 teeth, not having prophylaxis within the last month before the initial examination and during the study Exclusion criteria: use of steroidal, nonsteroidal anti-inflammatory drugs, and antibiotics within 2 weeks before the start of the study, acute illness, pregnancy, smoking, or use of other tobacco products |
73 subjects Group 1: 35 analyzed Group 2: 30 analyzed |
Regarding the study duration, only the study of Park et al followed patients for 1 year, with the rest not more than 2 months. Moreover, 2 studies reported a priori calculations of sample sizes and considered in some way examining the reliability of the measurements carried out. Also, 4 studies used some type of compliance monitoring.
The inflammatory response of the periodontal tissues was assessed using the gingival index of Löe and Silness in the studies providing short-term data. This assessment was supplemented by indexes assessing gingival bleeding such as the Eastman interdental bleeding index, the gingival bleeding index of Ainamo and Bay, bleeding on probing, the papillary bleeding score of Loesche, and the sulcus bleeding index of Muhlemann and Son. In the long term study, periodontal inflammation was assessed by the gingival index of Löe and Silness and the gingival bleeding index of Ainamo and Bay.
The anatomic conditions of the periodontal tissues were reported as pocket depth, relative attachment loss, and gingival hypertrophy. Patient-reported outcomes could not be retrieved apart from information on possible adverse reactions. In addition, the trial investigators provided more comprehensive assessments on unwanted effects of the intervention in 4 studies. Data on costs or cost-effectiveness could not be retrieved from the studies included in this systematic review.
Risk of bias within studies
Table III presents the summary findings of the risk of bias assessment for the studies; more details can be found in Supplementary Table III .
| Domain | Study | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Clerehugh et al | Hickman et al | Ho and Niederman | Park et al | Park et al | Pucher et al | Sharma et al | Silvestrini Biavati et al | Singh | |
| 1 | Low | Unclear | Low | Unclear | Unclear | Unclear | Unclear | Unclear | Unclear |
| 2 | Low | Unclear | Unclear | Unclear | Unclear | Low | Unclear | Unclear | Unclear |
| 3 | Low | Low | Low | Low | Low | Low | Low | Low | Low |
| 4 | Low | Low | Low | Unclear | Unclear | Low | Unclear | Unclear | Low |
| 5 | Low | Low | Unclear | Low | Low | Unclear | Unclear | Low | Unclear |
| 6 | Low | Low | Low | Low | Low | Low | Low | Low | Low |
| 7 | Low | Low | Low | Low | Low | Low | Low | Low | Low |
| Summary | Low | Unclear | Unclear | Unclear | Unclear | Unclear | Unclear | Unclear | Unclear |
Only 1 study was judged to have a low overall risk of bias. Most of the rest were classified with an overall unclear risk of bias, mainly because of uncertainties regarding random sequence generation and allocation concealment. Blinding of the participants and the personnel providing the instructions was not feasible apart from 1 publication. However, in the context of our research design, there was no reason to believe that bias could be introduced because of absence of blinding in these cases. On the contrary, investigation of the procedures regarding blinding of the outcome assessment showed unclear risks for some trials. Risks from incomplete outcome data because of dropouts were unclear in 3 studies.
Results of individual studies, meta-analysis, and additional analysis
In the short term, powered toothbrushes provided an overall statistically significant benefit compared with manual toothbrushes with regard to the Löe and Silness gingival index (weighted mean difference, −0.079; 95% CI, −0.146 to −0.012; 95% prediction interval, −0.300 to 0.142; P = 0.021; n = 374; I 2 , = 83%) ( Fig 2 ). In addition, an overall statistically significant benefit with regard to the indexes assessing gingival bleeding was detected (standardized mean difference, −0.637; 95% CI, −1.092 to −0.183; 95% prediction interval, −2.106 to 0.832; P = 0.06; n = 342; I 2 = 76%) ( Fig 3 ). In the long term, only 1 study showed a statistically significant benefit with regard to both the gingival index (weighted mean difference, −0.220; 95% CI, −0.424 to −0.016; P = 0.035; n = 40) and the gingival bleeding index (weighted mean difference, −1.630; 95% CI, −3.206 to −0.054; P = 0.043; n = 40).
Analyses of data from the studies investigating rotation-oscillation toothbrushes, which formed the major body of evidence, did not detect an overall statistically significant benefit with regard to the gingival index (weighted mean difference, −0.061; 95% CI, −0.167 to −0.046; 95% prediction interval, −1.196 to 1.074; P = 0.264; n = 173; I 2 = 60%) ( Fig 4 ) or the indexes assessing gingival bleeding (standardized mean difference, −0.217; 95% CI, −0.501 to −0.068; 95% prediction interval, –0.842 to 0.408; P = 0.135; n = 193; I 2 = 0%) ( Fig 5 ). Overall, the quality of available evidence was considered to be low ( Table IV ).
| Quality assessment | Patients (n) | Effect | Quality | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Studies | Risk of bias | Inconsistency | Indirectness | Imprecision | Other | PT | MT | Absolute (95% CI) | |
| Löe and Silness gingival index (short-term follow-up) | |||||||||
| 7 | Serious ∗ | Serious † | Not serious | Not serious | None | 199 | 175 | MD 0.079 lower (0.146 lower to 0.12 lower) P = 0.021 |
⊕⊕◯◯ Low |
| Indexes assessing gingival bleeding (short-term follow-up) | |||||||||
| 7 | Serious ∗ | Serious † | Not serious | Not serious | None | 182 | 160 | SMD 0.637 lower (1.092 lower to 0.183 lower) P = 0.006 |
⊕⊕◯◯ Low |
| Löe and Silness gingival index for rotation-oscillation powered toothbrushes (short-term follow-up) | |||||||||
| 3 | Serious ∗ | Serious † | Not serious | Not serious | None | 85 | 88 | MD 0.061 lower (0.167 lower to 0.046 higher) P = 0.264 |
⊕⊕◯◯ Low |
| Indexes assessing gingival bleeding for rotation-oscillation powered toothbrushes (short-term follow-up) | |||||||||
| 4 | Serious ∗ | Not serious | Not serious | Not serious | None | 95 | 98 | SMD 0.217 lower (1.501 lower to 0.068 higher) P = 0.135 |
⊕⊕⊕◯ Moderate |
∗ Most articles included were considered to be at unclear risk of bias
With regard to probing pocket depth, a statistically significant benefit of powered over manual toothbrushes was observed in the short term (weighted mean difference, −0.760; 95% CI, −1.029 to 0.491; P = 0.000; n = 24). However, in the long term, no difference was demonstrated (weighted mean difference, −0.140; 95% CI, −0.324 to 0.044; P = 0.136; n = 40). Similarly, no differences were detected in the long term for relative attachment loss (weighted mean difference, −0.230; 95% CI, −0.590 to 0.130; n = 40; P = 0.210) 26 or in the short term for gingival hypertrophy (relative risk, 0.667; 95% CI, 0.140 to 3.172; n = 20; P = 0.610). The quality of evidence was assessed as low ( Supplementary Table IV ).
Only 2 studies presented data on patient-reported outcomes in the form of information on possible adverse reactions, with no complaints reported. Finally, in the 4 studies where the trial investigators provided more comprehensive assessments on unwanted effects of the intervention, there was no evidence of adverse events or safety considerations to the soft or hard tissues or the fixed orthodontic appliances due to participation in the study or use of study products.
Risk of bias across studies
It was not possible to conduct analyses for small-study effects or publication bias.
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