The Effects of Oscillating-Rotating Electric Toothbrushes on Plaque and Gingival Health: a Meta-Analysis

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______Research Article ______The effects of oscillating-rotating electric toothbrushes on plaque and gingival health: A meta-analysis

JULIE GRENDER, PHD, RALF ADAM, PHD & YUANSHU ZOU, PHD

ABSTRACT: Purpose: To compare the effects of oscillating-rotating (O-R), sonic (side-to-side), and manual toothbrushes on plaque and gingival health after multiple uses in studies up to 3 months. Methods: A meta-analysis was conducted on randomized clinical trials (RCTs) up to 3 months in duration to evaluate O-R electric toothbrush effectiveness regarding gingivitis reduction and plaque removal versus sonic and/or manual toothbrushes. To ensure access to subject-level data, this meta-analysis was limited to RCTs involving O-R toothbrushes from a single manufacturer conducted from 2007 to 2017 for which subject-level data were available and that satisfied criteria of duration, parallel design, examiner-graded, etc. For gingivitis studies, a one-step individual subject meta-analysis was used to assess direct and indirect treatment differences and to identify any subject-level covariates modifying treatment effects. In the two-step meta-analysis, individual participant data were first analyzed in each study independently using the last timepoint (up to 3 months), producing aggregate data for each study. Then forest plots were produced using these aggregate data with random-effects models. For plaque studies, the efficacy variables were standardized so direct comparisons could be generated using the 2-step meta-analysis. Network meta-analysis was performed to assess the indirect plaque comparisons. Results: 16 parallel group RCTs with 2,145 subjects were identified assessing gingivitis via number of bleeding sites. In five and 11 gingivitis studies assessing O-R brushes versus manual and sonic brushes, respectively, a change in the average number of bleeding sites of -8.9 (95% CI: -15.9, -1.9) and -3.1 (95% CI: -3.8, -2.4) was observed (P≤ 0.008). These reductions equate to a 50% and 28% bleeding benefit for O-R technology versus the respective controls. The sonic brush bleeding change versus manual was -5.9 (P= 0.062), a 34% bleeding benefit. Utilizing individual bleeding scores, subjects with localized or generalized gingivitis (≥ 10% bleeding sites) had 7.4 times better odds of transitioning to generally healthy (< 10% bleeding sites) after using an O-R brush versus manual. 20 parallel design RCTs with 2,551 subjects assessed plaque (TMQHI, RMNPI). In eight and 12 plaque RCTs assessing an O-R brush versus manual and sonic brushes, respectively, standardized changes in average plaque scores of –1.51 (95% CI: -2.17, -0.85) and -0.55 (95% CI: -0.82, -0.28) were observed (P< 0.001). These plaque reductions by O-R equate to a relative 20% and 4% greater benefit, respectively. The change for sonic versus manual was -0.93 (95% CI: -1.48, -0.38); (P< 0.001) which equates to a 12% plaque benefit. (Am J Dent 2020;33:3-11).

CLINICAL SIGNIFICANCE: This subject-level meta-analysis of studies up to 3 months provides sound evidence supporting recommendations for patients with various degrees of gingival bleeding to use oscillating-rotating electric toothbrushes over manual and sonic toothbrushes to improve plaque control and gingival health.

: Dr. Julie Grender, Procter & Gamble, 8700 Mason-Montgomery Road, Mason, OH 45040, USA. E-: [email protected]

Introduction In addition to regular dental prophylaxes and professional care, toothbrushing for mechanical plaque biofilm disruption A notable development in the history of toothbrushing was and removal continues to be the core component of the oral the 1960s debut of the electric (i.e. power) toothbrush. This hygiene regimen. Realistically, a majority of individuals do not mechanized brush promised more efficient plaque removal with accomplish thorough brushing with a basic manual brush10-12 less user effort than a manual toothbrush. Later-generation, more and therefore gingivitis prevalence rates are high globally.13 streamlined electric toothbrushes with differing brush head Electric toothbrushes and brush head configurations have movement modalities, speeds, and filament arrangements were been designed to provide greater disruption of plaque and to subsequently introduced (e.g., side-to-side, circular in one- 1 access regions that harbor plaque and are associated with direction, ionic, oscillating-rotating). Via continued research and greater bleeding and disease. Physical plaque removal is development, many modern electric toothbrush models also offer accomplished by different mechanisms depending on the advanced safety and efficiency features like pressure sensors, electric toothbrush type. timers, brushing modes, and need-specific bristle designs. The Oral-B oscillating-rotating (O-R) electric toothbrush Toothbrush designs to maximize cleaning are based on the uses a small round brush head to contour to the shape of the precept that dental plaque is the predominant driver of gingival tooth, emulating the cleaning generated by a professional bleeding and disease.2.3 In the absence of plaque control, a prophylaxis handpiece. The filaments rotate in one direction localized inflammatory response manifests in gingival bleeding, and then another in a continuous succession for plaque biofilm edema, and erythema.4-7 Without intervention, chronic inflam- disruption and removal, which has been supported by clinical mation ensues in susceptible individuals and can culminate in and safety data.1,14-16 Toothbrushes frequently termed ‘sonic’ periodontitis with tissue destruction and potential bone and typically have more traditionally-shaped brush heads that subsequent tooth loss.8,9 vibrate side-to-side at a high rate of speed and are characterized Grender et al $PHULFDQ-RXUQDORI'HQWLVWU\9RO1R)HEUXDU\ E\DVLQJXODUKDUPRQLFWRQH7KHSODTXHUHPRYDOHIIHFWLYHQHVV Statistical analysis - )RU JLQJLYDO EOHHGLQJ ERWK RQHVWHS DQG RIPDQXDO25DQGRUVRQLFWRRWKEUXVKHVKDVEHHQHYDOXDWHG WZRVWHS PHWDDQDO\VLV DSSURDFKHV ZHUH XVHG 7KH RQHVWHS LQ V\VWHPDWLF UHYLHZV DQG PHWDDQDO\VHV KRZHYHU WKH\ LQGLYLGXDO VXEMHFW PHWDDQDO\VLVXVLQJ PL[HG PRGHO ZDV XVHG ZHUH FRQGXFWHG ZLWKRXW WKH EHQHILW RI DFFHVV WR WKH LQFOXGHG WR DVVHVV GLUHFW DQG LQGLUHFW WUHDWPHQW GLIIHUHQFHV ZLWK FRU VWXGLHV¶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¶V ZLWK DW OHDVW PLOG JLQJLYLWLV DV FODVVLILHG DW WKH WLPH RI WKH VWDQGDUG GHYLDWLRQ ZKLFK ZDV WKHQ XVHG WR JHQHUDWH GLUHFW LQYHVWLJDWLRQ,QWHUYHQWLRQ25WRRWKEUXVK&RPSDUDWRUVRQLF FRPSDULVRQV DFURVV VWXGLHV XVLQJ WZRVWHS PHWDDQDO\VLV RU PDQXDO WRRWKEUXVK 2XWFRPHV QXPEHU RI EOHHGLQJ VLWHV 7KUHH DVVXPSWLRQV IRU QHWZRUN PHWDDQDO\VLV KRPRJHQHLW\ IURP *LQJLYDO %OHHGLQJ ,QGH[ *%, /|H6LOQHVV *LQJLYDO WUDQVLWLYLW\DQGWUHDWPHQWUDQNFUHGLELOLW\ ZHUHHYDOXDWHGDQG ,QGH[ /6*, 3DSLOODU\ %OHHGLQJ ,QGH[ 3,%, 0D]]D VDWLVILHG 1HWZRUN PHWDDQDO\VLV ZDV SHUIRUPHG XVLQJ *LQJLYDO ,QGH[ *, DQG SODTXH VFRUH XVLQJ 7XUHVN\¶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ဨDQDO\VLV ZDV FRQGXFWHG LQ DJUHHPHQW ZLWK WKH HUURUV RI WKH IUHTXHQWLVW QHWZRUN PHWDDQDO\VLV HVWLPDWHV 3 SULQFLSOHVRIWKH35,60$VWDWHPHQWDQGKDVEHHQSRVWHGRQ VFRUHVZHUHFDOFXODWHGDVPHDQVRIRQHVLGHG3YDOXHVZKLFK SURYLGHGWKHUDQNLQJRIWKHWUHDWPHQWVE\PHDVXULQJWKHPHDQ FOLQLFDOWULDOVJRY H[WHQWRIFHUWDLQW\WKDWDWUHDWPHQWLVEHWWHUWKDQWKHFRPSHWLQJ Search process - 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