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Powered Toothbrushes: a Review of Clinical Trials

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Powered Toothbrushes: a Review of Clinical Trials J Clin Periodontol 1999; 26: 407–420 Copyright C Munksgaard 1999 Printed in Denmark . All rights reserved ISSN 0303-6979 Review article P. A. Heasman and G. I. McCracken Powered toothbrushes: a review The Dental School, Framlington Place, Newcastle upon Tyne NE2 4BW UK of clinical trials Heasman PA, McCraken GI: Powered toothbrushes: a review of clinical trials. J Clin Periodontol 1999; 26: 407–420. C Munksgaard, 1999. Abstract. There is now a vast range of powered toothbrushes (PTBs) available on the market and the efficacy of each product is usually determined in one, or a series of controlled clinical trials. This article reviews briefly the design of PTBs, some of the proposed indications for their use, and the principal observations from published studies of these products. The important issues regarding the regulation and design of trials involving PTBs are discussed and some recommendations are Key words: powered; electric toothbrushes; clinical trial design proposed with a view to developing a more structured approach to testing these products. Accepted for publication 21 September 1998 As an introduction to a review of the than those of conventional, manual O an audible clicking mechanism to problems and results of studies on man- brushes. The bundles of bristles are ar- warn the brusher when a pre-set ual and powered toothbrushes, Ash ranged either in rows (as for a conven- brushing force has been reached; (1964) wrote ‘‘Although power tooth- tional toothbrush) or in a circular pat- O timers. brushes are not particularly recent in tern mounted in a round head. Bristles Movement of the brushheads is pow- origin, advanced designs, intensive pro- are also arranged as more compact, ered from simple battery units, mag- motion and widespread use of many single tufts which facilitate interproxi- netostrictive devices or piezo-electric types and manufacture have stimulated mal cleaning and brushing in less ac- elements which are mounted in the considerable interest and research into cessible areas of the mouth. All brushes handles or stems of the brushes (Hot- their safety and effectiveness’’. This in- rely primarily upon the abrasive, mech- ta & Aono 1992, Terezhalmy et al. troductory statement remains perfectly anical contact between the bristles and 1995a). In addition to the effect of valid 35 years later and as the number the tooth surface to effect cleaning. The mechanical brushing, the concept of ut- of marketed products increases, the vol- traditional designs of head operate with ilising low-frequency acoustic energy to ume of published clinical research data a conventional side-to-side, arcuate or generate dynamic fluid activity and per- pertaining to the efficacy of these new back and forth motions whereas circu- haps a mild cavitation effect has been designs also continues to expand. lar brushheads have oscillating, rota- developed to provide a ‘beyond the The principal aims of this article are tional or counter-rotational move- bristle tip’ cleaning activity (Engel et al. to present a brief overview of the clinical ments. 1993, Johnson & McInnes 1994, Em- trials which have been undertaken to A number of the new generation ling & Yankell 1997, Stanford et al. evaluate the efficacy of powered tooth- powered toothbrushes also incorporate 1997). Acoustic vibrations produced in brushes and to consider design elements design features which are aimed at im- vitro have been shown to have signifi- of trials which may be standardised so proving the efficacy of cleaning and re- cant effects in reducing the abilities of that more meaningful comparisons of ducing the likelihood of toothbrush ab- oral bacteria to adhere to hard surfaces data from different studies can be made. rasion and gingival trauma in the long (McInnes et al. 1990, 1992, 1993, Wu- Firstly, however, the design and actions term (Heasman 1998a). These features Yuan et al. 1994). In a recent review, of powered toothbrushes will be review- include; Walmsley (1997) questioned whether ed together with the clinical indications O an active brush tip to facilitate even transient cavitation can be gener- for the use of these brushes. plaque control around posterior ated by powered toothbrushes and sug- teeth and at interdental sites; gested that acoustic microstreaming is O an orthodontic head for brushing the more likely physical phenomenon Design and actions of powered around and beneath the components whereby relatively large hydrodynamic toothbrushes of fixed orthodontic appliances; shear forces that are capable of dis- Generally, the brushheads of powered O rotating/spiralling filaments for in- rupting dental plaque, are produced toothbrushes tend to be more compact terproximal cleaning; from relatively low streaming velocities 408 Table 1. Studies comparing the efficacy of powered and manual toothbrushes Study Design/PTB type Indices Observations McKendrick et al. Parallel groups Oral Hygiene Index (Greene & Vermillion 1969) No evidence that the PTB was more effective than MTB in Heasman & McCracken (1968) 103 University students (18–33 years) Periodontal Index (modified) (Russell 1956) reducing oral debris, calculus formation or periodontal 24 months Gingival recession disease. Arcuate movement of PTB with conventional head Influence of instructions minimal. design Each brush used both with, or without verbal instruction Walsh & Glenwright Split mouth, crossover Plaque indexa) No differences in efficacy of plaque removal between MTB (1986) 10 dental students with healthy gingival and PTB. 14 day period Rotary brush Glavind & Zeuner Parallel groups matched for plaque Plaque score (% surfaces after disclosing) Improvements in plaque score and gingival bleeding were (1986) 40 adults with CAPD (22–67 years) Gingival bleeding comparable between both groups at 3 months. 20 patients used PTB with verbal instructions All patients using PTB indicated that they would 20 patients used oral hygiene kit with self teaching recommend the brush to others. manual 3 month follow-up Rotary toothbrush Killoy et al. Parallel groups Plaque indicesb,c) Significantly better plaque removal with PTB compared (1989) 24 patients Surface area plaque assessment (digitization of to MTB when measured using O’Leary and Turesky indices. 4 weeks photographs) No differences with surface area index – lack of Rotary toothbrush Bleeding index (Barnet et al. 1980) discrimination at interproximal sites. 3 episodes of oral hygiene instructions given Significant between – and within – group reductions in verbally gingival index. Walsh et al. Parallel groups Plaque indexa) PTB and MTB (∫irrigation) were equally effective in (1989) 108 subjects (18–65 years) Gingival indexd) reducing plaque, stain, bleeding to probing depth ratio 6 months Bleeding after probing (% sites) and % of pockets greater (or equal to) 4 mm. Conventional head, alternate up/down movement. Probing pocket depth Toothbrushing ∫irrigation Attachment loss Stain (Yankell et al. 1982) Boyd et al. 1989b Parallel groups Plaque indexa) PTB is equally effective in removing plaque and controlling (Murray et al. 1989) 40 subjects with moderate CAPD (age and sex Gingival indexb) gingivitis as the MTB (with adjunctive aids) in patients matched) in maintenance phase Bleeding tendencye) on a maintenance programme. 12 months Probing pocket depth No differences between groups with respect to creating a Rotary toothbrush Culture and darkfield microscopy of subgingival less pathogenic microflora. MTB used with floss and woodsticks microflora Baab and Johnson Parallel groups Plaque indexc) PTB more effective in removing plaque and controlling (1989) 40 adults with moderate gingivitis (mean age 31 Gingival indexd) gingivitis than MTB although at the end of the trial, years) Gingival bleeding indexd) scores for the groups were 4 weeks Plaque index: PTB – 28% Rotary toothbrush with instructions given verbally MTB – 50% All subjects given PTB at end of the study Gingival index: PTB – 1.28 MTB – 1.43 6 months after the study the majority of subjects no longer used the PTB. Preber et al. I Parallel groups Plaque scores (% after disclosing) Median plaque scores lower for PTB group (28%) than (1991) 19 dental hygiene students MTB group (39%) at the end of the study. 3 weeks Rotary toothbrush II Parallel groups Photographs (lower anterior region) of plaque Significantly more plaque removed with PTB than with 10 dental hygiene students retained after 15, 30, 60 s of brushing MTB. Abstained from oral hygiene for 4 weeks Rotary toothbrush Verbal instructions Hotta & Aono Parallel group Plaque indexc) No difference between brushes in their ability to remove (1992) 26 dental students (23–37 years) plaque. Piezo-electronic brush Plaque allowed to accumulate overnight and then brushed Silverstone et al. Parallel groups Plaque indicesa,b) Significant improvement in Quigley & Hein index for PTB (1992) 24 subjects matched for age, sex and plaque Gingival indexd) group (1.8»0.9) compared to MTB group (1.6»1.2). 6 weeks Questionnaire Both brushes reduced gingival index by a similar, but non- Rotary toothbrush significant magnitude (0.9»0.65). Quigley & Hein index more sensitive than Loe & Silness. No correlation between changes in Quigley & Hein index and gingival index. Barnes et al. Parallel groups Plaque indexa) Significant reductions in whole mouth and interproximal (1993) 70 adults with gingivitis Gingival indexd) gingivitis scores for PTB (but not MTB) 12 weeks No significant differences between groups in plaque Rotary toothbrush reduction. Instructions by video
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