CAT FINAL MILLS v2

8974052 1
Are Electric Toothbrushes
More Effective In Reducing
Plaque Than Manual
Toothbrushes?
Supervisor: Professor Nicholas Grey
Word Count: 3,758
Student ID: 8974052

8974052 2
Abstract
Background
Plaque-associated diseases, such as gingivitis and periodontal disease are widely
prevalent among the UK population; a study conducted by the Adult Dental Health
Survey (2009) found that “66% of dentate adults had visible plaque on at least one
tooth.” It has been suggested that such diseases have “considerable impacts on
individuals and society and are costly to treat” (Batchelor, 2014). Treatment of
plaque-associated diseases may consist of scaling (sub and/or supra elements) and
also “at home care” e.g. the use of toothbrushes, of which there are a wide range.
Patients therefore, may struggle to decipher which product is the most effective. This
paper aims to identify whether ‘powered’ toothbrushes are more effective than
manual toothbrushes in reducing plaque.
Method
Cochrane, PubMed and Medline databases were searched for studies that compared
the efficacy of electric and manual toothbrushes in reducing plaque. Studies were
required to be tested on humans and to be in ‘full English text.’ A total of three
studies were found to be suitable.
Results
All three studies conclusively found that electric toothbrushes were statistically
significant in reducing plaque, compared to manual toothbrushes.
Conclusion
With the set criterion, there is not enough ‘high quality’ evidence to suggest that
electric toothbrushes are more effective in reducing plaque than manual toothbrushes.
Therefore, further research is required in order to strengthen available evidence.

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Contents
1. Background
Clinical Scenario
4
4
Introduction
Dental Plaque
Prevalence
Aetiology
Potential Treatment Options
4
4
4
5
5
2. ResearchQuestion 8
3. Identification of Studies 8
4. Search Results and Inclusion Criteria 9
5. Critical Appraisal 13
6. Summary 16
7. Implications for Future Practice and
Research
20
8. Researchprotocol 21
9. Bibliography 24

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1) Background
Clinical scenario
A patient presents with high plaque and bleeding scores. The patient states they are
currently using a manual toothbrush and wonders whether a ‘powered’ toothbrush
would be more effective in reducing their plaque and bleeding scores. “Delivering
Better Oral Health” (2014) helps provide advice on reducing the incidence of plaque-
associated diseases by suggesting the “brushing of the gum line and each tooth twice
daily either with a manual or powered toothbrush.”
The patient states that they have seen ‘powered’ toothbrushes advertised and
wondered whether they were worth the investment.
You are unsure whether powered are more effective in reducing plaque than manual
toothbrushes and therefore, decide to consult available literature.
Introduction
Dental Plaque
Dental plaque is defined “as the soft deposits that form the biofilm adhering to the
tooth surface” (Sudhakar et al., 2008) and is “composed of organic and inorganic
materials derived from saliva, crevicular fluid and bacterial products.” (Rao, 2012)
Dental plaque is described as the “aetiological agent” (Seneviratne CJ, 2016) for both
gingivitis and periodontal disease and as a result may “affect the course and
pathogenesis of a number of systemic diseases, such as cardiovascular disease,
bacterial pneumonia, diabetes mellitus and low birth weight.” (Xiaojing Li, 2000)
Gingivitis may present as bleeding and/or reddened gingivae, eventually resulting in
bone or clinical attachment loss to the surrounding periodontium; (Periodontitis.)
Periodontitis may also present with recession, excessive probing depths and mobile
teeth.
Prevalence
Gingivitis is common in “early childhood, more prevalent and severe in adolescence
and tends to level off in older age groups” (Burt, 2005). However, periodontitis is
more likely seen in older patients than younger patients “due to many years of
exposure and the various risk factors associated with periodontitis.” (Noble, 2012)
Periodontitis also has a higher prevalence among men than in women, yet this may be
attributed to lower dental attendance rates that are associated with men.

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Aetiology
The ‘environmental determinants’ that affect microorganisms in the development of
plaque can be categorised into four factors (Fig. 1) Moreover, for both gingivitis and
periodontitis there are established ‘risk’ (smoking and stress) and ‘background
factors’ (age, gender, ethnicity, and genetics) that allow the development of such
diseases to become more likely.
Potential Treatment Options
Treatment of plaque induced diseases such as gingivitis and periodontitis ‘can be
improved by the sole use of oral hygiene.’ Renz et al., (2007) However, depending on
the severity of the disease it may be necessary for the dental care professional to
remove deposits of calculus and potential stagnation sites. This may hinder an
individual’s ability to effectively remove deposits in addition to controlling any
potential risk factors to the disease such as smoking, diabetes, and/or diet.
Oral hygiene instruction given by the dental care professional and ‘at home care’ is
synergistic; in order to ensure effective plaque removal the patient must be shown
how to effectively remove deposits; by use of either a ‘powered’ or manual
toothbrush.
environmental
determinants
Physicochemical
Water
pH of saliva
Adhesion,
Aggregation
and
Coaggregation
Nutritional
Diet
Host
Protection
Amount of
saliva
Fig. 1: Environmental Determinants (Perioexpertise.com,
2016)

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For use of manual toothbrushes, ‘the modified bass technique’ (as shown below in
Fig. 2) is the recommended way of brushing and was shown to have a “2.9 fold
effectiveness over normal practices in reducing plaque.” Poyato-Ferrera M, (2016)
‘Powered’ toothbrushes may be divided into several categories, the most common
types being the oscillating-rotating, which has a smaller rounded head, and the sonic.
Sonic powered toothbrushes, as shown in Fig. 3, have a vibrating side-to-side motion
and bare some resemblance to that of the manual toothbrush in both appearance and
instrumentation. When using Sonic powered toothbrushes patients, as with a manual
toothbrush, must adopt small circular rolling movements and angle the toothbrush 45-
degrees towards the gingival margin. In contrast, it is not necessary when using the
oscillating-rotating powered toothbrush, to adopt the use of small circular movements,
as the toothbrush itself does this automatically.
Fig. 2: The Modified Bass Technique (MEDCHROME, 2013)

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A key factor to consider is the possibility that the population who own either
‘powered’ toothbrushes (sonic or oscillating-rotating) or manual toothbrushes have
differing understandings of how to use them effectively. A study in Sweden in 2013
conducted by the Sahlgrenska Academy, University of Gothenburg showed that most
people did in fact brush their teeth on a regular occurrence, yet, ‘only a few’ knew the
best brushing technique.’ (Jensen O, 2016)
The recommended brushing time as mentioned by “Delivering Better Oral Health”
(2014) is two minutes; however, most people over estimate their brushing time.
Manufacturers and supporters of electric toothbrushes claim the effectiveness of
electric toothbrushes over manual toothbrushes comes from both the built in timers
(mostly set at 2-3 minutes;) which many electric toothbrushes now have, and also
reduction of skill required in order to effectively use them (less pressure and less
movement.)
Fig. 3: Oscillating-rotating and Ultrasonic (Best Oral Hygiene, 2014)

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2) ResearchQuestion
Are electric toothbrushes more effective in reducing plaque than manual
toothbrushes?
To formulate an effective research question I used the PICO format:
Population: Patients suffering from plaque induced diseases, e.g. Gingivitis
Intervention: Electric toothbrushes
Comparison: Manual toothbrushes
Outcome:Reduction in plaque-induced diseases and overall plaque levels
3) Identification of studies
The followingprimary conceptswereidentified:
-Plaque
-Manual toothbrushes
-Electric toothbrushes
-Powered toothbrushes
Searches were then made using the following databases:

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Cochrane databases 18/10/15
Number Searches Results
1 Powered toothbrush 5
2 Electric toothbrush 2
3 Plaque 44
4 Manual toothbrush 5
5 1 and 3 and 4 4
6 2 and 3 and 4 1
7 5 or 6 7
8 7 Publication date
>2000
7
PubMed (Medline) 18/10/15
1 Powered or Electric
Toothbrush
457
2 Plaque 88926
4 1, 2 and 3 193
5 Limit 4 to
 Full text
 Human
 English language
 Publish date
after 2000
 Ages 18-65 years
32
Embase 1974 to 2015 week 49 (Ovid)
1 Powered toothbrush or
electric toothbrush
142
2 Plaque 114778
4 1 and 2 and 3 4
4 Limit 4 to:
 Full text
 Human
 English language
 Publication date
after 2000
 Ages 18-65 years
2

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4) Searchresults and inclusion criteria
Inclusion criteria
Patients:
 Had at least 20 fully-erupted permanent teeth
 Did not have implants
 Patients were not wearing fixed or removable appliances
 Patients were fit and healthy, with no impairments other than an established
gingival disease
 Were 18-65 years of age
 Did not have established severe periodontal disease
Studies:
 Must look at plaque levels
 Randomized controlled trials must be over 4 weeks
 Must compare manual toothbrushes to electric toothbrushes
 No other dentifrices used in the study e.g. floss
 ionic toothbrushes not included within studies
Accepted Studies
Of the 41 studies identified from the databases 3 were found to be suitable (below)
1. Zimmer S. et al., (2002). Clinical efficacy of a new sonic/ultrasonic
toothbrush.
2. Dentino A.R. et al., (2002). Six-month comparison of powered versus manual
toothbrushing for safety and efficacy in the absence of professional instruction
in mechanical plaque control.
3. Mielczarek A., Banach, J. and Górska, R., (2013). Comparison of
Effectiveness of Manual and Electric Toothbrushes in Elimination of Dental
Plaque and Gingivitis Reduction. (*)
Articles within the systematic review (*) were subsequently researched, allowing the
following study to be accepted:
 Jain, Y. (2013). A comparison of the efficacy of powered and manual
toothbrushes in controlling plaque and gingivitis: a clinical study- gave
instructions
Rejected Studies
A Cochrane review, such as “Powered versus manual tooth brushing for oral health”
(Yaacob et al.,., 2014) is regarded as the “gold standard” in scientific research.
However, due to a plethora of reasons; e.g. the inclusion of children and orthodontic
patients no studies form this systematic review could be accepted. A further

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systematic review, Mielczarek, A., Banach, J. and Górska, R. (2013) was also cross-
referenced for studies that met the inclusion criteria; allowing Jain, Y. (2013) to be
accepted. Many results from the databases were also found to be irrelevant to the
subject or included patients with medical impairments. A full explanation of rejected
studies can be seen in the diagrams below.
Cochrane
7 results
5 Irrelevant
2 Excluded
1 study
systematic review
(Yaacob et al., 2014)
1 study
looked at different modes of
toothbrushes and did not compare
to manual toothbrushes
(Deacon et al., 2010)
Embase
2 results
1 Irrelevant
1 systematic review
(Mielczarek, A., Banach,J. and Górska, R,
2013)
Cross Referenced
(Mielczarek, A., Banach,J. and Górska, R, 2013)
to find
(Jain Y, 2013)

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Pubmed
32 results
2 Included
(Zimmer S et al., 2002)
(DentinoAR et al., 2002)
4 irrelevent 26 excluded
7 studies
included orthodontic patients
(MariniI et al., 2014) (Erbe C et al.,
2013) (Costa MRet al., 2010)
(Hickman J et al., 2002) (PG,2005)
(Thienpont V et al., 2001) (Costa MR
et al., 2007)
7 studies
included patients with severe
peridontal disease
(McCracken GI et al., 2004) (Bogren
A et al.,,2008) (Bogren A et al., 2007)
(Sicilia A et al., 2009) (Haffajee AD et
al., 2001) (GugerliP et al., 2007)
(Lazarescu D et al., 2003)
1 study
compared different types of
electric toothbrushes not
comparingthem to manual
toothbrushes
(Claydon N et al., 2004)
4 studies
included patients with medical
impairments
(Sharma A et al., 2012) (Doğan MC et
al., 2004) (Yuen HK et al.,2011)
1 study
included patients with implants
(Vandekerckhove B et al., 2004)
1 study
used other dentrifices (floss)
(Rosema NA et al., 2008)
3 studies
no full text available
(Williams K et al., 2004) (PizzoG et al.,
2010)(Terézhalmy GT et al., 2005)
1 study involved Hygienists
brushingfor the patients
(Danser MM et al., 2003)
1 study used an ionic toothbrush
(van der Weijden et al., 2002)

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Study Patient group Intervention Details Outcomes Assessed Key Results Study Type, Including Strengths, Weaknesses and
Potential Bias
ZimmerS, et
al.,.(2002)
PubMed
Berlin, Germany
64 subjects (32 males
and32 females)
63 completedthetrial,
one subject excluded
from analysis because of
missinglast examination
Inclusion Criteria:
 A PBI (Papillary
BleedingIndex,
Mühlemann& Son
1971) pertooth ≥
0.5
 A PI (Quigley-
Hein Plaque Index
1962) pertooth ≥
2.0
Exclusion Criteria:
 Severe Periodontal
Disease
 Long-term use of
anti-inflammatory
drugs
 Removable
Dentures
 Less than 20
Natural teeth
 Regular use of an
electric toothbrush
during the past year
After a screeningexaminationand
stratificationby age, sexand
papillary bleeding index(PBI), the
participants were randomly assigned
to two groups with 32 subjects in
each.
The two toothbrushes usedwere as
follows:
1. A poweredtoothbrush: Ultra
sonexUltima ®
2. A manual toothbrush: (Aronal
öko dentkompakt, medium,
31 tufts, GABA, Lörrach,
Germany)
Subjects were providedwith a
professional tooth cleaning and
given the same toothpaste (Elmex,
GABA, Lörrach,Germany.)
Subjects were given OHI by a person
not involvedin thestudy and
instructedtobrush for 3 mins fortwo
times/dayandwere providedwith an
hour glass (GABA)
-Electric toothbrush technique:
instructions to followthe
manufacturer’s recommendations
-Manual toothbrush Technique:
ModifiedBass
*Duringthe study period, mouth
rinses, gels andthe use of any
interdental cleaningaids were
prohibited
All examinations were
treatment blindand
performedby one
examiner
Clinical Parameters:
1.The Approximal
Plaque index(API)
(Lange et al.,.1977)
Qualitative(yes/no
decision)
2.Tureskymodification
(1970)of the Quigley-
Hein Plaque index (PI)
Ratedon a scale of 0-4
3.The Papillary
Bleeding Index(PBI)
(Mühlemann & Son
1971)
Ratedon a scale of 0-5
* All recordedat
baseline, andagain at 4
and8 weeks
At baseline, there was no
statistically significant difference
between any indexes.
Approximal Plaque Index:
There were nostatistically
significantdifferences after4 and
8 weeks (p>0.001)
Plaque Index:
A statisticallysignificant
difference was foundafter 4 and 8
weeks (p<0.001)At theendof the
study the median PI for themanual
group was 1.96 comparedto0.92
for the poweredgroup.
PapillaryBleedingindex:
A statisticallysignificant
difference was foundafter 4 and 8
weeks (p<0.001)At theendof the
study the median PBI for the
manual group was 0.63 comparedto
0.29 for thepoweredgroup.
Overall:
The poweredbrush resultedin
markedreductions but not in
complete removal ofplaque.
Regardingthe PI and PBI the
Ultra sonexUltima ®was more
efficacious in removingplaque and
preventinggingivitis than the
manual toothbrush.
Randomisedparallel-designtreatment-blindstudy over
an 8-week period
 Stratifiedrandomisation
 Standardizedconditions: groups given same
toothpaste
 Instructions given by someone not involvedin the
study
 All subjects toldto brush for the same amount of
time
 p value= 0.001
 Toothpastewas weighedfollowingcompletion to
determine whether subjects hadoveror under
used
 8 weeks
 Intra examiner reliability was testedwith repeated
measurements
 Statistical analysis was performedwith SPSS9.0
program
 The Mann-WhitneyU-test was usedfor non-
parametric unrelatedsamples
 Friedmann test was usedfor non-parametric
relatedsamples
 Justifiedbrushingtime for 3 mins (recommended
in Germany)
 Sample size of only 63 subjects, 1 exclusionfrom
analysis
 Age range of subjects not mentioned
 Single-blind
 Unclear whether subjects were given OHIby the
same person
 Potential for Hawthorne effect
 No power calculationdone
 Study fundedby Sonex Deutschlandtherefore,
givingthe potential forbias
 No explanationof the randomisationprocess
 Median toothpaste use for the manual brush was
61.9gand72.0gfor the electric brush
 Qualitativeplaque assessment (API) not
appropriate for this study
5) Critical Appraisal

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Study Patient group Intervention Details Outcomes Assessed Key Results Study Type IncludingStrengths,
Weaknesses and Potential Bias
Jain,Y. (2013)
Embase
Gurgaon
(Haryana),
India.
60 Dental Students of bothsexes,
with ages rangingfrom 18-28years.
Inclusion criteria:
 Goodgeneral andoral health
 No periodontal therapyduring
the past three months
 Moderate gingivitis (at least
25% of test sites showing
bleedingon probing)
 Ability to attendthe hospital at
recall intervals
 All teeth present,except third
molars
Exclusion criteria:
 Poor manual dexterity
 Use of drugs that couldaffect
the stateof the gingival tissues
 Current orthodontictherapy
 Muco-gingival problems
 5 or more carious teethrequiring
immediate treatment
 Use of any other supplemental
plaque control measures,such as
interdental cleansingaids or
mouthwashes
 A habit of takingalcohol,
smokingor chewingtobacco
Eligible subjects were stratified
andrandomized to one ofthe
two brushinggroups.
Randomisation was carriedout by
using the coin toss method by a
secondexaminer who was not
involvedin the recordingof
clinical parameters.
Group A (n=30)
Toothbrush: (Manual) Oral B®
Classic ultraclean medium
Dentifrice: Pepsodent®
Technique: Modified Bass
Duration ofbrushing: 2 mins
Group B (n=30)
Toothbrush: (Powered) Oral B®
vitalitydual clean
Dentifrice: Pepsodent®
Technique: Bristles
perpendicular togingival
margin
Duration ofbrushing: 2 mins
Prior tothe study Scalingand
polishingwas done for all
subjects, andtheir baseline scores
were made zero.
Toldto returnat 1,2 and6 weeks
Clinical findings were
recordedat one, two
and six weeks at six
sites on each tooth
(distobuccal,mid-
buccal, mesio-buccal,
disto-lingual,mid-
lingual and
mesiolingual.)
Three Clinical
Parameters:
-Plaque Index
(O’Leary,1972) with
aid of a disclosing
agent: AlphaPlacDPI
-Oral Hygiene Index-
Simplified (Greenand
Vermillon, 1964)
-Gingival Index(Loe
andSilness, 1963)
*Carriedout with a
William’s
Periodontal probe
and a mouth mirror
under a dental light.
Plaque Index(O’Leary,1972):
2 weeks:
Group B hadstatistically significantlylower (p=
0.0014) mean plaque scores (44.033)comparedto
Group A (60.255)
6 weeks:
Group B hadstatisticallysignificantly(p= <0.001)
lower mean plaque scores (20.491) comparedto
Group A (43.786)
Oral HygieneIndex-Simplified (Green and
Vermillon, 1964)
The meanOral Hygiene score forGroup A fell
from 0.596on the7th
day to 0.196on the42nd
day.
Group B also showeda decline from 0.703on the
7th
day to 0.18onthe 42nd
day. However, in
comparingthetwo groups there was no statistically
significant difference.
Gingival Index(Loe andSilness, 1963)
The meanGingival score for Group A fell from
1.156 on the 7th
dayto 1.038on the42nd
day.
Group B also showeda decline from1.145on the
7th
day to 1.018 onthe 42nd
day, however, in
comparingthetwo groups there was no statistically
significant difference.
Overall:
There was a definite andgradual improvement in
reduction of plaque andhealth ofgingiva observed
in both groups by the sixthweek. However,the
subject groupusingthe poweredtoothbrush
demonstratedclinical andstatistical improvement
in overall plaque scores.
6 week (45days), Parallel arm,
Double Blind RCT
 Showed methodof
randomisation
 No drop outs
 All subjects maintainedrecall
appointments
 Double-blind
 Both groups given the same
toothpaste
 Used a pairedt-test
 p- Value set at 0.05
 Proformapreparedforthe
study
 Author reports not conflicts of
interest
 Subgroups/parameters
comparedandevaluatedusing
student’s t-test
 Unpairedt-test used
 6 weeks
 60 subjects
 Includeddental students,who
will knowthe correct way to
brush their teeth
 Did not showhowsubjects
were stratified
 Used the coin toss methodfor
randomisation
 No power calculation
 No specifiedamount of
toothpaste stated
 Toothpastewas not weighed
during or at theendof the trial
to see over/underuse
 Hawthorneeffect
 No female: male ratioshown
 No fundingsource stated
 Not clear who carriedout OHI

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Study Patient group Intervention Details Outcomes Assessed Key Results Study Type IncludingStrengths, Weaknesses
and Potential Bias
Dentino
AR et al.,
(2002)
PubMed
Wisconsin
(USA)
Medically healthy
subjects (18-65
years)
172 subjects met
screeningcriteria
157 subjects
finishedthe trial
15 subjects did
not finish trial
Screening
criteria:
(performedby a
Periodontist)
Inclusion
Criteria:
-Modified
Gingival Index
(MGI) of at least
1.2
-20% or more
sites showing
bleedingon
probing
-No previous
experience usinga
powered
toothbrush
Natural Teeth
Patients were stratifiedby gender,
MGI, plaque indexandsmoking via
a computer program andrandomly
assignedto two groups:
1. OscillatingRotatingPowered
toothbrush (PB) (n=76)
2. ADA acceptedstandardsoft-
bristle Manual toothbrush (M)
(n=81)
Instructions given:
1. (PB) Group toldtoread
manufacturer’s instructions
2. (M) Group providedwith an
ADA approvedpamphlet
3. Both groups were toldtoabstain
from flossing/mouthwash or any
other dentifrices than those
provided
4. Both groups toldto brush two
times/day for 2 mins
Other:
 All subjects were given the
same toothpaste (Crest,
Procter& Gamble)
 Patients were given a
prophylaxis at baseline
 No timer was given to MB
group
 PB group hadbuilt in timer to
toothbrush
 Both groups toldto returnat 3
months for
measurements/assessments and
replacements of toothbrushes
andheads
A total of 157 subjects were assessed:
PB (n=76) and M (n=81)
Calculus andstain assessments: (single examiner)
consistedof two parts (canines were not included)
1. Volpe-Man holdcalculus index: assessedon
lingual surfaces of mandibular incisors, usinga
UNC probe. Analysedas a meanvalue per tooth
2. Claydon stain index:facial surfaces of maxillary
and mandibular incisors
Measures of inflammation
1. Gingival Crevicular Fluid (GCF): single
examiner 4 sites per tooth,on randomly selected
patients (n=126), GCF samples collectedfrom
posterior interproximalsites using a standard
method(collectedfor 30 secs) results collected
using an electronic impedance device)
2. Lobene Modified Gingival Index: (2 calibrated
examiners)Facial/lingual, marginal tissue and
interproximal papillaescoredon a scaleof 0-3,
full mouth means calculated
3. Percent ofsites with Bleedingon Probing
(BOP): (Dual examiner)Using a UNC probe and
a dichotomous indexon 6 sites per tooth,30 secs
after probing (bleeding present/absent)
Measure of plaque
1. Turesky modification ofthe plaque index- used
disclosing solution, and calculated at baseline 3
and 6 months
Time spent brushing
When subjects returned at 3 and6 months, they were
instructed to brush in a room separate to the examiner
and were timed withouttheir knowledge.
Calculus andstain assessments:
1. Volpe-Man holdcalculus index:
PB users were foundto havelower
calculus levels at 3 months
(p=0.0304) and6 months
(p=0.0078)
2. Claydon stain index:No statistical
significant differencefor stain
between PB andM groups, even
though values at 3 & 6 months
numerically favouredPB users.
Measures of inflammation
PB group’s change from baseline
remainedgreater in all tests at the 6-
monthassessment, but therewas no
significant statistical difference
Measure of plaque
1. Turesky modification ofthe
plaque index
At 3 months: Greaterreductionin full
mouth plaque levels of PB (0.29)
comparedtoM (0.13) (p=0.027)
At 6 months:Statisticallysignificantly
lower plaque levels for PB (1.09)
comparedtoM (1.39) (p=0.0025)
Time spent brushing
PB (125 secs), M (84secs) (p=0.0157)
(PB) 50/76spent 2 mins brushing (M)
14/81 spent 2 mins brushing
6 month, single-masked parallel design,
randomised clinical trial.
 6 months
 157 subjects completedthe trial
 Pairedt-tests
 Shown stratificationprocess
 Analysis of variance (ANOVA)
 Analysis of covariance (ANCOVA)
 Power calculation done (80%)
 Patients were stratifiedusinga computer
program
 All given the same toothpaste
 Patients screenedby periodontist
 Single examiner for calculus andstain
assessment showedstrongreproducibility
 Notedthe state of thetoothbrushes when they
came back for recall,tosee whether they had
been used or not
 Bristle splayingshowedall subjects hadused
the brush
 Baseline measurements showedthe
population as a whole enteredwith gingivitis
 No explanationof the randomisationprocess
 15 did not complete the trial
 Unclear which groups the 15dropouts were
from
 Members of the same householdwere given
the same toothbrush
 Toothpastewas not weighedat endof study
 Time constraints not all patients’GCF
measured
 Funded by Braun/Oral B®
 Limitedusefulness of stainassessment:
subjects startedwith stainvariability
 Inclusion of smokers; reductionin BOP
 Only includedCaucasian race
 Female heavy
 More smokers in manual group (7more)
 Single examiner

8974052 16
6) Summary
Notable similarities and differences in approach
The three independent studies carried out by Zimmer S, et al., (2002), Jain, Y. (2013)
and Dentino AR, et al,. (2002) have notable similarities and differences along with
strengths and weaknesses of which are highlighted below:
Patient group
Studies conducted by Zimmer S, et al.,(2002) and Jain, Y. (2013) had a similar size
subject group of 63 and 60, respectively. However, the study conducted by Dentino
AR, et al., (2002) had an overall larger subject group of 157. In terms of age ranges
that were included in the studies, both Jain, Y. (2013) and Dentino AR, et al., (2002)
involved subjects that were ≥ 18, and even though within Zimmer S, et al., (2002) the
study the age range is not specified, we can assume this was also the case as search
parameters for PubMed were set at 18-65 years.
For the inclusion criteria, the percentage of teeth showing Bleeding on Probing (BOP)
was used for Jain, Y. (2013) and Dentino AR, et al., (2002); however, other differing
indices (such as Modified Gingival index and Papillary Bleeding Index) were also
used to determine the presence of gingivitis among the study population.
Dentino AR, et al., (2002) within their sample chose to include smokers (which the
other studies excluded) and confined the population to Caucasian races only.
Exclusion criteria for Dentino AR, et al., (2002) and Zimmer S, et al., (2002) was
similar in that both studies rejected subjects with previous experience using powered
toothbrush, this was not specified in Jain, Y. (2013)
Intervention Details
All three studies claimed to be randomized, however, only Jain, Y. (2013) actually
stated the method used (a coin toss.) In addition, Both Zimmer S, et al., (2002) and
Dentino AR, et al., (2002) chose to stratify subjects by gender along with plaque and
bleeding indices, however the chosen stratification method was not specified in the
study carried out by Jain, Y. (2013)
Supplemental plaque controls such as, interdental cleaning aids and/or mouthwashes
were prohibited during the course of all three studies, in order to help control
independent variables. Subjects at baseline were also given both a prophylaxis and set
of oral hygiene instructions prior to the commencement of the study.
Verbal oral hygiene instructions were given in Zimmer S, et al., (2002) compared to
Dentino AR, et al., (2002) in which they were written. Specification as to whether
subjects received verbal or written instructions was not mentioned in the study carried
out by Jain, Y. (2013)
Within the three studies the same toothpaste was given to both groups in order to
maintain standardized conditions; however, in comparing the three studies all chose

8974052 17
different dentifrices: Pepsodent®, Elmex® and Crest®. However, only Zimmer S, et
al., (2002) weighed the toothpastes used by the subjects; so as to determine whether
toothpaste had been over or under used.
Outcomes assessed:
Zimmer S, et al., (2002) and Dentino AR, et al., (2002), both used the Turesky
Modification of the Plaque Index (1970) in order to look at plaque levels to determine
success. Jain, Y. (2013) differed by choosing the O’Leary plaque index (1972) to
measure outcomes.
All three studies included further differing indices to measure superiority. For
example, Jain, Y. (2013) included the OHI-S Green and Vermillon. (1964), Zimmer
S, et al., (2002) included the API Lange et al., (1977) and PBI Mühlemann & Son
(1971) indices; whereas, Dentino AR, et al., (2002), included calculus, stain and
inflammation indices. Outcomes were assessed by single examiners for Zimmer S, et
al.,(2002) and Dentino AR, et al.,. (2002); however, Jain, Y. (2013) failed to mention
who outcome assessments were carried out by.
Jain, Y. (2013)
A disadvantage of this study was that no power calculation was shown. As there was
no justification of the sample size; it becomes difficult to say, whether a sample size
of 60 is a satisfactory and accurate representation of the population. However, a
positive aspect of the study was that there were no withdrawals and both men and
women were included.
The inclusion of dental students may have been a potential disadvantage as they are
not an accurate representation of the wider population; it is likely that most of the
students were aware of the correct way to brush their teeth regardless of the
instructions they were given and what groups they were assigned to. The “Hawthorne
effect” is also likely to of occurred in this study along with Zimmer S, et al., (2002)
and Dentino AR, et al., (2002).
Males and females were said to be included within this study; however it fails to
specify the female to male ratio; making it difficult to distinguish whether the study as
a whole was female/male heavy, or if within the two groups one group was more
female/male heavy.
An advantage of this study was that it was randomised and the method was shown;
removing any investigator bias. Yet, in the same token the chosen coin toss method is
a disadvantage as it may produce high unpredictability. Alternatively, using a
computer to carry out randomisation would have reduced any potential for bias. In
addition, the study was double-blinded; helping to reduce the potential for operator
and patient bias.
Furthermore, the p-value was set at 0.05 and t-tests were used in order to calibrate the
statistical significance of data. A further advantage was that the author reported no
conflicts of interest.

8974052 18
Although an effort was made to keep all independent variables the same; giving all
subjects the same toothpaste (Pepsodent®) There was no mention of how much
toothpaste should be used by the subjects; therefore, patients could have over/under
used the toothpaste; potentially causing lower plaque levels and a reduction in
gingivitis in one group compared to the other.
To rectify this, the specific amount of toothpaste required for use could have been
specified at the beginning of the trial and/or toothpaste could have been weighed
during and/or after the trial was completed; as was done by Zimmer S, et al., (2002)
Zimmer S, et al., (2002)
Like Jain, Y. (2013) no power calculation was shown; therefore, a total sample size of
63 (one excluded from analysis) is potentially too small to be representative. In
addition, a confidence interval was not included within the study; this was also the
case in Jain, Y. (2013) and Dentino AR, et al., (2002)
At the beginning of the study, there was an equal male to female ratio, however, it
was not clear which group the excluded subject was from and whether they were in
fact female/male.
In terms of intervention the randomisation procedure used was stratification by age,
sex and papillary bleeding index; this is advantageous as it ensures similarity between
the two groups. Again, no further explanation was given as to how randomisation
took place.
The researches maintained independent variables such as toothpaste well; all subjects
were provided with the same toothpaste Elmex®; this was also weighed at the end of
the study to identify over or under use. The median toothpaste use for the manual
group was 61.9g and 72.0g for the powered toothbrush; which could be regarded as a
potential amplification of results in favour of the electric toothbrush.
For key results, the p-value was set at 0.001 and both the Mann-Whitney U-test and
Friedmann test were used for non-parametric unrelated and related samples. Intra
examiner reliability was also tested with repeated measurements, which can be seen
as an advantage to the study. Yet, in the same token the study was carried out by a
single examiner, increasing risk of bias.
Like Jain, Y. (2013) and Dentino AR, et al., (2002) it again becomes questionable
whether the subjects of this study were victim to the “Hawthorne Effect;” exaggerated
brushing could have occurred in the days leading up to examination.
Furthermore, the study conducted by Zimmer S, et al.,(2002) was funded by Sonex
Deutschland; the overall outcome of the study suggests the superiority of the powered
Ultra Sonex Ultima over the manual toothbrush; opening up speculation of funding
bias.

8974052 19
Dentino AR, et al., (2002)
The study conducted by Dentino AR, et al., (2002) had a larger sample size (157
subjects) than Jain, Y. (2013) and Zimmer S, et al., (2002); even though 15 failed to
complete the trial. An advantage of the study done by Dentino AR, et al., (2002)
compared to Jain, Y. (2013) and Zimmer S, et al., (2002) was that a power calculation
of 80% had been carried out; to allow a detection of a true difference between the two
treatment groups. This study was also carried out for the longest period of time (6
months), compared to the other two studies appraised, increasing the validity of the
study.
The patient group, like Jain, Y. (2013) required subjects to be at least 18 years old,
however, in comparison Dentino AR, et al., (2002) chose to include patients over the
age of 44. By including older patients (who are potentially less manually dexterous)
the study conducted by Dentino AR, et al., (2002) is able to represent a more diverse
range of ages better.
A disadvantage of the study was the inclusion of smokers; which were not included in
Jain, Y. (2013) and Zimmer S, et al., (2002) With the inclusion of smokers there is a
danger of inaccurately reporting a reduction in bleeding on probing as well as
inflammation and erythema, due to the vasoconstrictive properties of smoke.
Members of the same household were included in this study; the members were also
given the same toothbrush; these subjects may have influenced each other throughout
the study, potentially skewing results.
A Periodontist carried out screening and potential subjects were required, (as in Jain,
Y. (2013) to have at least 20% or more sites with bleeding on probing; confirming all
subjects entered the study with gingivitis. A further advantage to the study was that
patients were randomised by stratification using a computer (gender, MGI, plaque
index and smoking) however, as was the same in Zimmer S, et al., (2002), there was
no specification on how randomisation was carried out.
The study conducted by Dentino AR, et al., (2002) used more clinical parameters than
the other two studies to test the superiority of one group over the other, as the clinical
question was also researching the safety of the toothbrushes, however, these will not
be discussed. Dentino AR, et al., (2002) in comparison to Jain, Y. (2013) and Zimmer
S, et al., (2002) chose to look at stain, calculus and inflammation. However, the
inclusion of the Claydon Stain Index could be seen as a disadvantage as it is of little
significance; subjects could have entered the trial with stain variability.
This study was a single blinded and single examiner study; meaning there was
potential for bias. In order to compare outcomes between and within the two groups a
number of statistical analyses were carried out such as, analysis of variance
(ANOVA,) analysis of covariance (ANCOVA) and paired t-tests; the p-value was also
set at 0.05.
Lastly, the study was supported by Braun® and Oral-B® questioning the potential for
funding bias.

8974052 20
Conclusion:
All three studies appraised were similar in patient grouping, study design, and
concluding results; statistically significant differences in levels of plaque existed
when comparing electric toothbrushes to manual toothbrushes.
However, there were a number of problems with the three studies; such as funding
and sample size that reduce the studies’ integrity. Even though, the Cochrane review
conducted by Yaacob et.al.,( 2014) conclusively decided that powered toothbrushes
were in fact better than manual toothbrushes in terms of oral health, the inclusion
criteria for the systematic review differed from those included within this critically
appraised topic. Moreover, Yaacob et.al.,( 2014) suggested within the Cochrane
review that results from the studies included were of “moderate quality;” suggesting
that further trials are needed to be able to confidently implement change within
clinical practice.
7) Implications for Future Practice and Research
Clinical practice
As mentioned before; the current advice given by “Delivering Better Oral Health”
(2014) on reducing plaque induced diseases, (e.g. gingivitis) fails to specify which out
of a powered and manual toothbrush should be chosen by the patient. Instead,
emphasis is placed on the importance of twice daily self-care over professional
cleaning, and stresses the importance of brushing the ‘Gum line.’
Furthermore, the findings of the three systematic reviews appraised, correlate to the
systematic review done by Yaacob et.al. (2014); electric are more effective than
manual toothbrushes regarding to oral health. However, as was discovered in Dentino
AR, et al., (2002), Jain, Y. (2013) and Zimmer S, et al., (2002); evidence used to draw
conclusions from the research trials used were of “moderate quality.” Yaacob et al., (
2014) Due to many factors, there is not ‘high quality evidence’ from Dentino AR, et
al., (2002), Jain, Y. (2013) and Zimmer S, et al., (2002) to support the superiority of
manual toothbrushes over powered toothbrushes with the set inclusion criteria.
For example, two out of the three RCT’s appraised used products from oral health
companies which actually funded the research (Braun®, Oral-B®, Sonex®.) As
marketed electric toothbrushes are generally more expensive than conventional
manual toothbrushes, oral health companies who market the powered toothbrushes,
such as Braun®, may have a particular interest in results favouring that particular
intervention group.
Moreover, small sample sizes, absences of power calculations and the inability to
control independent variables; (such as toothpaste use and brushing times) reduces the
quality of the evidence shown, even though it was shown to be statistically
significant. Evidently, this suggests the need for more high quality evidence regarding
the superiority of powered over manual toothbrushes in reducing plaque associated
diseases.

8974052 21
Research
As mentioned, an additional study is required in order to rectify weaknesses
highlighted in the three appraised studies; in order to produce a study with robust
evidence. Strengths from the three studies will be integrated as well as improvements;
this may be done in the following ways:
Patient sampling should look to exclude dental students and ensure the stratified
sample is actually representative of the population, perhaps by giving more
consideration to the inclusion of more races and not just age and sex. All independent
variables (e.g. toothpaste) in the study should be controlled more efficiently by
weighing the toothpaste in order to regulate over/under use.
A statistician should be employed to determine power calculations so as to ensure an
adequate sample size; to see statistically significant differences. Furthermore, a 6
month study should be regarded as minimum.
Lastly, in order to have no conflicts of interest, an independent funding source should
be sought.
8) ResearchProtocol
Title ‘Are electric toothbrushes more effective in reducing
plaque than manual toothbrushes?’
Aim To determine whether electric toothbrushes are more
effective in reducing plaque induced diseases (such as
gingivitis/periodontitis) and improving overall oral health
than manual toothbrushes
Null hypothesis Electric toothbrushes are no more effective in reducing plaque
than manual toothbrushes
Ethical Approval Approval will be sought from the local ethics committee prior
to commencement of the study
Study Design
Study type:
A 6 month, double-blinded/single-blinded, parallel, stratified randomized controlled
trial
Inclusion Criteria:
 At least 20 fully-erupted permanent teeth
 18-65 years of age
 No Implants or orthodontic patients of any kind

8974052 22
 Medically healthy patients with no impairments other than an established gingival
disease
 At least 20% or more sites with BOP and or/ PI (Quigley-Hein Plaque Index
1962) per tooth ≥ 2.0
Exclusion Criteria:
 Severe periodontal disease
 Smokers
 Patients with any previous experience of a powered toothbrush
 Subjects from the same households
Sampling:
 Recruitment of adults aged 18-65 years, will take place from hospitals and dental
practices within the UK.
 No subjects from same households
 Both males and females included, as well as different races.
 A statistician will carry out a power calculation of 80% to see a 0.05 statistically
significant difference
Treatment Protocol:
 Patients will be randomised by stratification in a double-blind fashion (age, sex,
race and plaque indices) into two treatment groups using a recognized computer
randomisation program.
 Group A will be given an electric toothbrush, while Group B will be given a
manual toothbrush.
 All independent variables will be controlled and accounted for.
Outcomes measured:
*Dual examiner, measured at baseline, three and six months.
1. Turesky modification (1970) of the Quigley-Hein Plaque index (PI)
calculated using a registered disclosing solution
2. Percent of sites with Bleeding on Probing (BOP): Using a UNC probe and a
dichotomous index on 6 sites per tooth, 30 secs after probing (bleeding
present/absent)
Analysis of results
Statistical tests will be used in order to determine statistical significance of outcomes:
 t-tests
 ANCOVA

8974052 23
 ANOVA: will be used for comparisons of treatment groups in regards to age,
gender, sex and race
 95% confidence interval levels
 p value (0.05)
Resource requirements and budget
An independent sponsor will be sought out so as to have no conflicts of interest
Time frame
Six months
Expected outcome
Electric toothbrushes will prove superior to manual toothbrushes in reduction of
plaque levels
Dissemination of results
Results and evidence form the study will be appraised appropriately and changes
implemented in practice as necessary

8974052 24
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8974052 25
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