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Cochrane Database of Systematic Reviews

Powered versus manual toothbrushing for oral health

Information

DOI:
https://doi.org/10.1002/14651858.CD002281.pub3Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 17 June 2014see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Oral Health Group

Copyright:
  1. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Munirah Yaacob

    Department of Periodontics, Kulliyyah of Dentistry, International Islamic University Malaysia (IIUM), Kuantan, Malaysia

  • Helen V Worthington

    Correspondence to: Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Manchester, UK

    [email protected]

  • Scott A Deacon

    South West Cleft Unit, Frenchay Hospital, Bristol, UK

  • Chris Deery

    Department of Oral Health and Development, University of Sheffield, Sheffield, UK

  • A Damien Walmsley

    Department of Prosthetic Dentistry, School of Dentistry, Birmingham, UK

  • Peter G Robinson

    School of Clinical Dentistry, University of Sheffield, Sheffield, UK

  • Anne‐Marie Glenny

    Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Manchester, UK

Contributions of authors

Bill Shaw and Helen Worthington wrote the protocol. Anne‐Marie Glenny, Bill Shaw, Mike Heanue, Peter Robinson, Damien Walmsley and Munirah Yaacob co‐ordinated the review. Bill Shaw and Peter Robinson wrote the letters to the authors. Bill Shaw, Scott Deacon, Chris Deery, Mike Heanue, Peter Robinson, Damien Walmsley and Munirah Yaacob independently and in duplicate assessed the eligibility of trials, extracted data and assessed the quality of the trials. Damien Walmsley and Peter Robinson provided the background and sourced information on brush action and plaque and gingival indices. Helen Worthington conducted the statistical analysis. Scott Deacon, Anne‐Marie Glenny, Munirah Yaacob and Mike Heanue checked and entered data. Anne‐Mare Glenny, Helen Worthington and Munirah Yaacob wrote this version of the review, and checked for numerical consistency. Chris Deery updated the background.

Sources of support

Internal sources

  • School of Dentistry, The University of Manchester, UK.

  • School of Dentistry, The University of Birmingham, UK.

  • Edinburgh Dental Institute, UK.

  • University of Sheffield, School of Dentistry, UK.

  • MAHSC, UK.

    The Cochrane Oral Health Group is supported by the Manchester Academic Health Sciences Centre (MAHSC) and the NIHR Manchester Biomedical Research Centre.

External sources

  • Cochrane Oral Health Group Global Alliance, UK.

    All reviews in the Cochrane Oral Health Group are supported by Global Alliance member organisations (British Association of Oral Surgeons, UK; British Orthodontic Society, UK; British Society of Paediatric Dentistry, UK; British Society of Periodontology, UK; Canadian Dental Hygienists Association, Canada; Mayo Clinic, USA; National Center for Dental Hygiene Research & Practice, USA; New York University College of Dentistry, USA; and Royal College of Surgeons of Edinburgh, UK) providing funding for the editorial process (http://ohg.cochrane.org/).

  • National Institute for Health Research (NIHR), UK.

    CRG funding acknowledgement:
    The NIHR is the largest single funder of the Cochrane Oral Health Group.

    Disclaimer:
    The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.

Declarations of interest

Bill Shaw and Helen Worthington were co‐researchers on a randomised controlled trial sponsored by Braun AG (Clerehugh 1998) through a grant to The University of Manchester. Damien Walmsley was a consultant and undertook laboratory trials of powered toothbrushes sponsored by Braun AG through a grant to the University of Birmingham.

Acknowledgements

Thanks are due to Anne Littlewood and Sylvia Bickley, Trials Search Co‐ordinator for the Cochrane Oral Health Group for carrying out the searches for the review; Philip Riley and Liz Asbridge for administration of the review, co‐ordination of databases and location of articles for the review; Luisa Fernandez Mauleffinch, Managing Editor for the Cochrane Oral Health Group for copy editing the review; and Bill Shaw and Mike Heanue for their contribution to previous versions of this review. For help with the translations of foreign papers our thanks go to Selva Can (German), Dr Mona Nasser (German), Dr Patrick Sequeira‐Byron (German), Regina Mitezki (German), Paul Tramini (French), Professor Stéphanie Tubert‐Jeannin (French) and Giovanni Lodi (Italian).
We would also like to thank the following investigators who replied to our requests for additional information about their trials: J de Boever (Universitair Ziekenhuis, Gent), C Burge (University of Colorado), M Darby (Old Dominion University), A Dentino (Marquette University), W Killoy (University of Missouri), A Koerber (University of Illinois), I Moschén (Leopold‐Franzens‐Universität), R Nolden (Rheinishe Friedrich‐Wilhelms Universität), T Palmer (Clinical Research Associates), M Thompson (Gillette Company), P Warren (Gillette Company), AK Pelka (University Hospital of Munich), C Kossack (University of Berlin) and G.I MacCracken (Newcastle University). For their help as referees, we express our thanks to Martin Addy, Nik Barstow, Robin Davies, Marco Esposito, Eleanor Grey, Jayne Harrison, Lee Hooper, Ian Needleman, Richard Niederman, Derek Richards and Philip Riley.

Version history

Published

Title

Stage

Authors

Version

2014 Jun 17

Powered versus manual toothbrushing for oral health

Review

Munirah Yaacob, Helen V Worthington, Scott A Deacon, Chris Deery, A Damien Walmsley, Peter G Robinson, Anne‐Marie Glenny

https://doi.org/10.1002/14651858.CD002281.pub3

2005 Apr 20

Manual versus powered toothbrushing for oral health

Review

Peter Robinson, Scott A Deacon, Chris Deery, Mike Heanue, A Damien Walmsley, Helen V Worthington, Anne‐Marie Glenny, Bill C Shaw

https://doi.org/10.1002/14651858.CD002281.pub2

2003 Jan 20

Manual versus powered toothbrushing for oral health

Review

Mike Heanue, Scott A Deacon, Chris Deery, Peter G Robinson, A. Damien Walmsley, Helen V Worthington, W C Shaw, Bill C Shaw

https://doi.org/10.1002/14651858.CD002281

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Flow chart of study selection in this update.
Figures and Tables -
Figure 1

Flow chart of study selection in this update.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Funnel plot of Comparison 1: All powered toothbrushes versus manual toothbrushes, Outcome 1.1: Plaque scores at 1 to 3 months at all sites.
Figures and Tables -
Figure 4

Funnel plot of Comparison 1: All powered toothbrushes versus manual toothbrushes, Outcome 1.1: Plaque scores at 1 to 3 months at all sites.

Funnel plot of Comparison 1: All powered toothbrushes versus manual toothbrushes, Outcome 1.2: Gingival scores at 1 to 3 months at all sites.
Figures and Tables -
Figure 5

Funnel plot of Comparison 1: All powered toothbrushes versus manual toothbrushes, Outcome 1.2: Gingival scores at 1 to 3 months at all sites.

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.
Figures and Tables -
Analysis 1.1

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.
Figures and Tables -
Analysis 1.2

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.
Figures and Tables -
Analysis 1.3

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.
Figures and Tables -
Analysis 1.4

Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.
Figures and Tables -
Analysis 2.1

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.
Figures and Tables -
Analysis 2.2

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.
Figures and Tables -
Analysis 2.3

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.
Figures and Tables -
Analysis 2.4

Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.
Figures and Tables -
Analysis 3.1

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 2 Gingivitis scores at 1 to 3 months at all sites.
Figures and Tables -
Analysis 3.2

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 2 Gingivitis scores at 1 to 3 months at all sites.

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.
Figures and Tables -
Analysis 3.3

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.
Figures and Tables -
Analysis 3.4

Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.
Figures and Tables -
Analysis 4.1

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.
Figures and Tables -
Analysis 4.2

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.
Figures and Tables -
Analysis 4.3

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months.

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.
Figures and Tables -
Analysis 4.4

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Study

Plaque

Gingivitis

Costa 2007

No statistically significant pre‐post differences shown

No statistically significant pre‐post differences shown

Gugerli 2007

"Subjects using a power toothbrush during initial treatment reduced supragingival plaque to lower levels...than subjects using a manual brush"

"Subjects using a power toothbrush ...showed significantly less bleeding on probing than subjects using a manual brush"

Zimmer 2005

Median change in Quigely‐Hein at 4 weeks:

Powered (Cybersonic): 0.23

Powered (Braun 3D Excel): 0.07

Manual: 0.22

Median change in Quigely‐Hein at 8 weeks:

Powered (Cybersonic): 0.41

Powered (Braun 3D Excel): 0.08

Manual: 0.35

All indices showed statistically significant reductions for both power
toothbrushes which were superior to the manual brush

Median change in papillary bleeding index at 4 weeks:

Powered (Cybersonic): 0.25

Powered (Braun 3D Excel): 0.02

Manual: 0.39

Median change in papillary bleeding index at 8 weeks:

Powered (Cybersonic): 0.36

Powered (Braun 3D Excel): 0.10

Manual: 0.61

Figures and Tables -
Analysis 4.5

Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 5 Rotation oscillation versus manual: data not suitable for meta‐analysis.

Comparison 5 Circular powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.
Figures and Tables -
Analysis 5.1

Comparison 5 Circular powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Comparison 5 Circular powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.
Figures and Tables -
Analysis 5.2

Comparison 5 Circular powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 months.
Figures and Tables -
Analysis 6.1

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 months.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 2 Plaque scores at >3 months at all sites.
Figures and Tables -
Analysis 6.2

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 2 Plaque scores at >3 months at all sites.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 3 Gingivitis at 1 to 3 months.
Figures and Tables -
Analysis 6.3

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 3 Gingivitis at 1 to 3 months.

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months at all sites.
Figures and Tables -
Analysis 6.4

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months at all sites.

Study

Plaque

Gingivitis

Galgut 1996

The electrically active toothbrushes better plaque removal than the inactive toothbrushes (6.5% more plaque removal at final visit)

Not reported

Moreira 2007

Frequency distribution for plaque zero at baseline and 28 days was 9.27+/‐ 10.14/17.75+/‐9.60 and 8.42+/‐10.43/16.79+/‐8.93 for ionic and conventional toothbrushes respectively

Not reported

Figures and Tables -
Analysis 6.5

Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 5 Ionic versus manual: data not suitable for meta‐analysis.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.
Figures and Tables -
Analysis 7.1

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 month at all sites.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.
Figures and Tables -
Analysis 7.2

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months at all sites.
Figures and Tables -
Analysis 7.3

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3 months at all sites.

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.
Figures and Tables -
Analysis 7.4

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months.

Study

Plaque

Gingivitis

Costa 2007

"There was a significant difference for the ultrasonic/buccal group indicating that the ultrasonic brush improved plaque reduction on the buccal surfaces (p=0.007, Wilcoxon test)"

Marginal bleeding: "No significant differences were noted in the nine subgroups (p>0.05, Wilcoxon test)"

Zimmer 2005

"Improvements of the indices after 4 and 8 weeks were calculated for comparison between groups. After 4 and 8 weeks, with respect to all indices, the use of the power toothbrushes resulted in improvements which were statistically significant superior to what was found for the manual brush (p<0.001)." Results were presented as box‐plots with medians and 25, 75 percentiles. Non‐parametric tests have been used for the data analysis

"Improvements of the indices after 4 and 8 weeks were calculated for comparison between groups. After 4 and 8 weeks, with respect to all indices, the use of the power toothbrushes resulted in improvements which were statistically significant superior to what was found for the manual brush (p<0.001)." Results were presented as box‐plots with medians and 25, 75 percentiles. Non‐parametric tests have been used for the data analysis

Figures and Tables -
Analysis 7.5

Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 5 Ultrasonic versus manual: data not suitable for meta‐analysis.

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 months at all sites.
Figures and Tables -
Analysis 8.1

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 months at all sites.

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.
Figures and Tables -
Analysis 8.2

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3 months at all sites.

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 3 Gingival scores >3 months at all sites.
Figures and Tables -
Analysis 8.3

Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 3 Gingival scores >3 months at all sites.

Powered toothbrushes compared with manual toothbrushes for oral health

Patient or population: Individuals of any age with no reported disability that might affect toothbrushing

Intervention: Powered toothbrushes with any mode of action

Comparison: Manual toothbrushes

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Manual toothbrush

Powered toothbrush

Plaque scores at 1 to 3 months

Scale from: 0 to 5

The mean plaque score in the control group was 2.16 points1

The mean plaque score in the intervention groups was
0.23 lower (0.32 lower to 0.14 lower)

2871 (40 studies)

⊕⊕⊕⊝
moderate3,4

This effect represents an 11% reduction in plaque at 1 to 3 months

Long‐term data (>3 months) also showed a statistically significant reduction in plaque for powered toothbrushes compared to manual toothbrushes

Gingival scores at 1 to 3 months

Scale from: 0 to 3

The mean gingivitis score in the control group was 1.1 points2

The mean gingivitis score in the intervention groups was
0.07 lower (0.10 lower to 0.04 lower)

3345
(44 studies)

⊕⊕⊕⊝
moderate3,4

This effect represents a 6% reduction in gingivitis at 1 to 3 months

Long‐term data (>3 months) also showed a statistically significant reduction in gingivitis for powered toothbrushes compared to manual toothbrushes

Adverse events

There was no apparent relationship between the use of powered toothbrushes and soft tissue trauma. In part this finding was due to the very small number of adverse events reported in the trials

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

1. Based on median of control means for all trials presenting data using Quigley Hein index at 1 to 3 months

2. Based on median of control means for all trials presenting data using Löe and Silness index at 1 to 3 months

3. Downgraded due to statistically significant heterogeneity (I2 = 83% for plaque; I2 = 82% for gingivitis)

4. No downgrading was undertaken for risk of bias although 46/56 included trials were assessed as being at unclear risk of bias. Given that many of the studies were conducted over 10 years ago, it was felt much of the uncertainty may be due to poor reporting

Figures and Tables -
Table 1. Summary of inclusion criteria categories within included studies

Inclusion criteria

Number (n = 56)

Adults

43

Minimum number of teeth

31

Minimum periodontal baseline measures

28

Participants recruited from dental clinics

9

Concurrent fixed orthodontic treatment

8

Some participants aged less than 16 years

11

Volunteer university students

3

Dental students

2

School children

3

Figures and Tables -
Table 1. Summary of inclusion criteria categories within included studies
Table 2. Summary of exclusion criteria categories within included studies

Exclusion criteria1

Number (n = 56)

Exclusion criteria related to medical history

31

Pregnancy or lactation

5

Previous use of powered toothbrushes

6

Patients undergoing orthodontic treatment

9

Previous periodontal treatment

3

Dental students

2

Cervical restorations

1

Smoking

3

Maximum periodontal measure

8

Wearing partial denture

2

1 Not all trials explicitly stated exclusion criteria

Figures and Tables -
Table 2. Summary of exclusion criteria categories within included studies
Table 3. Summary of toothbrush modes of action, number of trials and participants

Mode of action

Trial ID

Number of trials

Number in trials

Side to side

Glass 1965, Ho 1997, Johnson 1994, Lobene 1964, McCracken 2009, Moritis 2008, O'Beirne 1996, Tritten 1996, Walsh 1989, Yankell 1997

10

988

Counter oscillation

Baab 1989, Khocht 1992, Stabholz 1996, Wilson 1993, Yukna 1993

5

267

Rotation oscillation

Ainamo 1997, Barnes 1993, Biavati Silvestrini 2010, Biesbrock 2007, Clerehugh 1998, Costa 2007, Cronin 1998, Dentino 2002, Dorfer 2009, Garcia‐Godoy 2001, Gugerli 2007, Haffajee 2001a, Heasman 1999, Hickman 2002, Lapiere unpublished, Lazarescu unpublished, McCracken 2004, Rosema 2008, Sharma 2000, Silverman 2004, Soparkar 2000, Sowinski 2000, Stoltze 1994, van der Weijden 1994, Warren 2001, Yankell 1997, Zimmer 2005

27

2159

Circular

Khocht 1992, Yankell 1996

2

162

Ultrasonic

Costa 2007, Forgas‐B 1998, Goyal 2007, Sharma 2010, Terezhalmy 1995, Zimmer 2002, Zimmer 2005

7

506

Unknown

Emling 1991, Kallar 2011, Singh unpublished, Soparkar 1964, Toto 1966

5

1130

Ionic

Galgut 1996, Moreira 2007, Pucher 1999, van Swol 1996

4

221

Four trials evaluated two powered toothbrushes

Figures and Tables -
Table 3. Summary of toothbrush modes of action, number of trials and participants
Table 4. Sensitivity analyses of all trials for all indices

Index

Group selected

Number of trials

SMD

Effect P value

Het. P value

I2

Plaque

1‐3 months

All trials

40

‐0.50 (‐0.70 to ‐0.31)

<0.0001

<0.0001

88

Full mouth

34

‐0.58 (‐0.80 to ‐0.36)

<0.0001

<0.0001

85

Low risk of bias

3

‐0.83 (‐2.02 to 0.36)

0.17

<0.0001

94

Manufacturer funded

26

‐0.56 (‐0.82 to ‐0.29)

<0.0001

<0.0001

88

Trials excluding ortho patients

36

‐0.46 (‐0.66 to ‐0.27)

<0.0001

<0.0001

83

Plaque

>3 months

All trials

14

‐0.37 (‐0.50 to ‐0.24)

<0.0001

<0.0001

86

Full mouth

13

‐0.39 (‐0.53 to ‐0.26)

<0.0001

<0.0001

87

Low risk of bias

2

0.12 (‐0.27 to 0.52)

0.53

0.51

0

Manufacturer funded

9

‐0.41 (‐0.56 to ‐0.25)

<0.0001

<0.0001

91

Trials excluding ortho patients

14 (all)

‐0.37 (‐0.50 to ‐0.24)

<0.0001

<0.0001

86

Gingivitis

1‐3 months

All trials

44

‐0.43 (‐0.60 to ‐0.25)

<0.0001

<0.0001

82

Full mouth

35

‐0.47 (‐0.68 to ‐0.25)

<0.0001

<0.0001

85

Low risk of bias

3

‐0.96 (‐1.95 to 0.03)

0.06

<0.0001

93

Manufacturer funded

32

‐0.47 (‐0.68 to ‐0.26)

<0.0001

<0.0001

84

Trials excluding ortho patients

38

‐0.42 (‐0.61 to ‐0.23)

<0.0001

<0.0001

83

 

Gingivitis >3 months

All trials

16

‐0.21 (‐0.31 to ‐0.12)

<0.0001

<0.0001

51

Full mouth

14

‐0.25 (‐0.37 to ‐0.13)

<0.0001

0.006

56

Low risk of bias

2

‐0.12 (‐0.52 to 0.27)

0.54

0.52

0

Manufacturer funded

10

‐0.21 (‐0.35 to ‐0.07)

0.003

0.003

68

Trials excluding ortho patients

16 (all)

‐0.21 (‐0.31 to ‐0.12)

<0.0001

<0.0001

51

SMD = standardised mean difference

Figures and Tables -
Table 4. Sensitivity analyses of all trials for all indices
Comparison 1. All powered toothbrushes versus manual toothbrushes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Plaque scores at 1 to 3 month at all sites Show forest plot

40

2871

Std. Mean Difference (IV, Random, 95% CI)

‐0.50 [‐0.70, ‐0.31]

1.1 Quigley Hein (Turesky)

28

2000

Std. Mean Difference (IV, Random, 95% CI)

‐0.39 [‐0.56, ‐0.22]

1.2 Silness and Löe

6

431

Std. Mean Difference (IV, Random, 95% CI)

‐0.94 [‐1.83, ‐0.05]

1.3 Visible plaque index Ainamo Bay

1

111

Std. Mean Difference (IV, Random, 95% CI)

‐0.26 [‐0.63, 0.12]

1.4 Ortho modification of Silness and Löe

1

60

Std. Mean Difference (IV, Random, 95% CI)

0.0 [‐0.51, 0.51]

1.5 Navy plaque index mod Rustogi

3

249

Std. Mean Difference (IV, Random, 95% CI)

‐1.13 [‐1.94, ‐0.31]

1.6 O'Leary index

1

20

Std. Mean Difference (IV, Random, 95% CI)

‐1.81 [‐2.88, ‐0.73]

2 Gingival scores at 1 to 3 months at all sites Show forest plot

44

3345

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.60, ‐0.25]

2.1 Löe and Silness

30

2109

Std. Mean Difference (IV, Random, 95% CI)

‐0.46 [‐0.66, ‐0.25]

2.2 Lobene gingival index

8

907

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.88, 0.03]

2.3 BOP

3

159

Std. Mean Difference (IV, Random, 95% CI)

‐0.19 [‐0.50, 0.12]

2.4 Papillary bleeding index 0‐4 scale

2

95

Std. Mean Difference (IV, Random, 95% CI)

‐0.11 [‐1.55, 1.33]

2.5 BOMP 0‐2 scale

1

75

Std. Mean Difference (IV, Random, 95% CI)

‐0.58 [‐1.04, ‐0.12]

3 Plaque scores at >3 months Show forest plot

14

978

Std. Mean Difference (IV, Random, 95% CI)

‐0.47 [‐0.82, ‐0.11]

3.1 Quigley Hein (Turesky)

11

736

Std. Mean Difference (IV, Random, 95% CI)

‐0.51 [‐0.97, ‐0.04]

3.2 Silness and Löe

2

131

Std. Mean Difference (IV, Random, 95% CI)

‐0.38 [‐1.09, 0.34]

3.3 Visible plaque index Ainamo Bay

1

111

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.66, 0.09]

4 Gingival scores at >3 months Show forest plot

16

1645

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.21 [‐0.31, ‐0.12]

4.1 Löe and Silness

5

318

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.27 [‐0.49, ‐0.05]

4.2 Lobene gingival index

4

440

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.14 [‐0.33, 0.04]

4.3 BOP

4

270

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.46 [‐0.70, ‐0.22]

4.4 Papillary bleeding index 0‐4 scale

1

32

Std. Mean Difference (IV, Fixed, 95% CI)

0.65 [‐0.07, 1.36]

4.5 BOMP 0‐2 scale

1

75

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.24 [‐0.69, 0.22]

4.6 PMA

1

510

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.16 [‐0.34, 0.02]

Figures and Tables -
Comparison 1. All powered toothbrushes versus manual toothbrushes
Comparison 2. Side to side powered toothbrushes versus manual toothbrushes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Plaque scores at 1 to 3 month at all sites Show forest plot

7

570

Std. Mean Difference (IV, Random, 95% CI)

‐0.27 [‐0.77, 0.23]

1.1 Quigley Hein (Turesky)

4

324

Std. Mean Difference (IV, Random, 95% CI)

‐0.14 [‐0.36, 0.08]

1.2 Silness and Löe

3

246

Std. Mean Difference (IV, Random, 95% CI)

‐0.78 [‐2.25, 0.68]

2 Gingival scores at 1 to 3 months at all sites Show forest plot

9

795

Std. Mean Difference (IV, Random, 95% CI)

‐0.32 [‐0.81, 0.17]

2.1 Löe and Silness

6

385

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.88, 0.32]

2.2 Lobene gingival index

3

410

Std. Mean Difference (IV, Random, 95% CI)

‐0.39 [‐1.24, 0.46]

3 Plaque scores at >3 months Show forest plot

3

272

Std. Mean Difference (IV, Fixed, 95% CI)

0.02 [‐0.21, 0.26]

3.1 Quigley Hein (Turesky)

2

218

Std. Mean Difference (IV, Fixed, 95% CI)

0.03 [‐0.24, 0.30]

3.2 Silness and Löe

1

54

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.53, 0.53]

4 Gingival scores at >3 months Show forest plot

3

272

Std. Mean Difference (IV, Fixed, 95% CI)

0.10 [‐0.14, 0.34]

4.1 Löe and Silness

1

54

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.53, 0.53]

4.2 Lobene gingival index

1

166

Std. Mean Difference (IV, Fixed, 95% CI)

0.16 [‐0.14, 0.47]

4.3 BOP

1

52

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.54, 0.54]

Figures and Tables -
Comparison 2. Side to side powered toothbrushes versus manual toothbrushes
Comparison 3. Counter oscillation powered toothbrushes versus manual toothbrushes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Plaque scores at 1 to 3 month at all sites Show forest plot

4

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Quigley Hein (Turesky)

4

184

Mean Difference (IV, Random, 95% CI)

‐0.03 [‐0.15, 0.10]

2 Gingivitis scores at 1 to 3 months at all sites Show forest plot

4

172

Std. Mean Difference (IV, Fixed, 95% CI)

0.01 [‐0.30, 0.31]

2.1 Löe and Silness

2

103

Std. Mean Difference (IV, Fixed, 95% CI)

0.01 [‐0.39, 0.40]

2.2 Lobene gingival index

1

40

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.03 [‐0.65, 0.59]

2.3 BOP

1

29

Std. Mean Difference (IV, Fixed, 95% CI)

0.06 [‐0.68, 0.79]

3 Plaque scores at >3 months Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

3.1 Quigley Hein (Turesky)

2

69

Mean Difference (IV, Fixed, 95% CI)

‐0.27 [‐0.48, ‐0.07]

4 Gingival scores at >3 months Show forest plot

2

69

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.19 [‐0.66, 0.29]

4.1 Lobene gingival index

1

40

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.18 [‐0.80, 0.44]

4.2 BOP

1

29

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.19 [‐0.93, 0.54]

Figures and Tables -
Comparison 3. Counter oscillation powered toothbrushes versus manual toothbrushes
Comparison 4. Rotation oscillation powered toothbrushes versus manual toothbrushes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Plaque scores at 1 to 3 month at all sites Show forest plot

20

1404

Std. Mean Difference (IV, Random, 95% CI)

‐0.53 [‐0.74, ‐0.31]

1.1 Quigley Hein (Turesky)

13

979

Std. Mean Difference (IV, Random, 95% CI)

‐0.44 [‐0.69, ‐0.20]

1.2 Silness and Löe

2

115

Std. Mean Difference (IV, Random, 95% CI)

‐1.17 [‐2.74, 0.40]

1.3 Visible plaque index Ainamo Bay

1

111

Std. Mean Difference (IV, Random, 95% CI)

‐0.26 [‐0.63, 0.12]

1.4 Ortho modification of Silness and Löe

1

60

Std. Mean Difference (IV, Random, 95% CI)

0.0 [‐0.51, 0.51]

1.5 Navy plaque index mod Rustogi

2

119

Std. Mean Difference (IV, Random, 95% CI)

‐0.72 [‐1.09, ‐0.35]

1.6 O'Leary index

1

20

Std. Mean Difference (IV, Random, 95% CI)

‐1.81 [‐2.88, ‐0.73]

2 Gingival scores at 1 to 3 months at all sites Show forest plot

21

1479

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐0.73, ‐0.26]

2.1 Löe and Silness

14

952

Std. Mean Difference (IV, Random, 95% CI)

‐0.68 [‐0.99, ‐0.38]

2.2 Lobene gingival index

3

290

Std. Mean Difference (IV, Random, 95% CI)

‐0.11 [‐0.46, 0.24]

2.3 BOP

2

130

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.59, 0.10]

2.4 Papillary bleeding index

1

32

Std. Mean Difference (IV, Random, 95% CI)

0.65 [‐0.07, 1.36]

2.5 BOMP 0‐2 scale

1

75

Std. Mean Difference (IV, Random, 95% CI)

‐0.58 [‐1.04, ‐0.12]

3 Plaque scores at >3 months Show forest plot

7

527

Std. Mean Difference (IV, Random, 95% CI)

‐0.66 [‐1.28, ‐0.03]

3.1 Quigley Hein (Turesky)

5

339

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.69, 0.24]

3.2 Silness and Löe

1

77

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.19, ‐0.26]

3.3 Visible plaque index Ainamo Bay

1

111

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.66, 0.09]

4 Gingival scores at >3 months Show forest plot

8

684

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.35 [‐0.50, ‐0.20]

4.1 Lobene gingival index

2

234

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.36 [‐0.62, ‐0.10]

4.2 BOP

2

189

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.64 [‐0.93, ‐0.34]

4.3 Löe and Silness

2

154

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.25 [‐0.57, 0.07]

4.4 Papillary bleeding index 0‐4 scale

1

32

Std. Mean Difference (IV, Fixed, 95% CI)

0.65 [‐0.07, 1.36]

4.5 BOMP 0‐2 scale

1

75

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.24 [‐0.69, 0.22]

5 Rotation oscillation versus manual: data not suitable for meta‐analysis Show forest plot

Other data

No numeric data

Figures and Tables -
Comparison 4. Rotation oscillation powered toothbrushes versus manual toothbrushes
Comparison 5. Circular powered toothbrushes versus manual toothbrushes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Plaque scores at 1 to 3 month at all sites Show forest plot

2

128

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.02 [‐0.37, 0.33]

1.1 Quigley Hein (Turesky)

2

128

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.02 [‐0.37, 0.33]

1.2 Silness and Löe

0

0

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Gingival scores at 1 to 3 months at all sites Show forest plot

2

128

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.18 [‐0.53, 0.17]

2.1 Löe and Silness

1

63

Std. Mean Difference (IV, Fixed, 95% CI)

0.13 [‐0.36, 0.63]

2.2 Lobene gingival index

1

65

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.50 [‐0.99, ‐0.00]

Figures and Tables -
Comparison 5. Circular powered toothbrushes versus manual toothbrushes
Comparison 6. Ionic toothbrushes versus manual toothbrushes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Plaque scores at 1 to 3 months Show forest plot

3

186

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.57 [‐0.87, ‐0.27]

1.1 Quigley Hein (Turesky)

2

116

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.30 [‐0.67, 0.06]

1.2 Silness and Löe

1

70

Std. Mean Difference (IV, Fixed, 95% CI)

‐1.07 [‐1.57, ‐0.57]

2 Plaque scores at >3 months at all sites Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2.1 Quigley Hein (Turesky)

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Gingivitis at 1 to 3 months Show forest plot

2

116

Mean Difference (IV, Fixed, 95% CI)

‐0.01 [‐0.04, 0.02]

3.1 Löe and Silness

2

116

Mean Difference (IV, Fixed, 95% CI)

‐0.01 [‐0.04, 0.02]

4 Gingival scores at >3 months at all sites Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.1 Löe and Silness

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

5 Ionic versus manual: data not suitable for meta‐analysis Show forest plot

Other data

No numeric data

Figures and Tables -
Comparison 6. Ionic toothbrushes versus manual toothbrushes
Comparison 7. Ultrasonic powered toothbrushes versus manual toothbrushes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Plaque scores at 1 to 3 month at all sites Show forest plot

4

301

Std. Mean Difference (IV, Fixed, 95% CI)

‐1.33 [‐1.59, ‐1.07]

1.1 Quigley Hein (Turesky)

3

171

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.97 [‐1.30, ‐0.63]

1.2 Navy plaque index mod Rustogi

1

130

Std. Mean Difference (IV, Fixed, 95% CI)

‐1.89 [‐2.30, ‐1.47]

2 Gingival scores at 1 to 3 months at all sites Show forest plot

5

354

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.99 [‐1.21, ‐0.76]

2.1 Löe and Silness

3

161

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.56 [‐0.88, ‐0.25]

2.2 Lobene gingival index

1

130

Std. Mean Difference (IV, Fixed, 95% CI)

‐1.80 [‐2.21, ‐1.39]

2.3 Papillary bleeding index 0‐4 scale

1

63

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.82 [‐1.34, ‐0.31]

3 Plaque scores at >3 months at all sites Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.1 Quigley Hein

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Gingival scores at >3 months Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.1 Löe and Silness

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

5 Ultrasonic versus manual: data not suitable for meta‐analysis Show forest plot

Other data

No numeric data

Figures and Tables -
Comparison 7. Ultrasonic powered toothbrushes versus manual toothbrushes
Comparison 8. Unknown or other action versus manual toothbrushes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Plaque scores at 1 to 3 months at all sites Show forest plot

2

Std. Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.1 Quigley Hein (Turesky)

2

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Gingival scores at 1 to 3 months at all sites Show forest plot

3

Std. Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2.1 Löe and Sillness

3

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Gingival scores >3 months at all sites Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.1 PMA

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 8. Unknown or other action versus manual toothbrushes