The Journal of EVIDENCE-BASED DENTAL PRACTICE

REVIEW ANALYSIS & EVALUATION // DIAGNOSIS/TREATMENT/PROGNOSIS

INSUFFICIENT EVIDENCE WITHIN A

SYSTEMATIC REVIEW AND META-ANALYSIS
OF POWERED TOOTHBRUSHES OVER
MANUAL TOOTHBRUSHES FOR SOFT
TISSUE HEALTH DURING ORTHODONTIC
TREATMENT
REVIEWERS
TERRI TILLISS, CLIFTON M. CAREY
The authors conducted a systematic review and meta-analysis to assess the quality of evidence comparing the effects of
powered and manual toothbrushes on inflammatory status of the periodontal tissues during orthodontic treatment.

SORT SCORE ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Short-term and long-term effectiveness of powered toothbrushes in promoting
A B C N/A
SORT, Strength of Recommendation Taxonomy.
periodontal health during orthodontic treatment: A systematic review and meta-
analysis. Al Makhmari SA, Kaklamanos EG, Athanasiou AE. Am J Orthod Den-
LEVEL OF EVIDENCE tofacial Orthop 2017;152(6):753-66.e7.
1 2 3
See page 8A for complete details regarding SORT and LEVEL OF
EVIDENCE grading system.

SUMMARY
SOURCE OF FUNDING Selection Criteria
None identified The search was conducted using 8 databases (PubMed, Cochrane Central Register
of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, Web of
Science Core Collection, Arab World Research Source, Clinical Trials.gov, ProQuest
TYPE OF STUDY/DESIGN Dissertations, and Theses Global) up to August 2017. There were no restrictions on
Systematic review with meta-analysis language, date, or status of publication. Included were randomized controlled trials
of at least 4 weeks duration that compared powered and manual toothbrushing in
regular everyday usage without supervision in orthodontic populations and re-
KEYWORDS ported periodontal health outcomes. Excluded were split-mouth designs, animal
Meta-analysis, Systematic review, research, noncomparative studies (case reports and case series), systematic re-
Power toothbrush, Orthodontics, views, and meta-analyses. Reference lists of eligible studies were also reviewed.
Periodontal health Two individuals, not blinded to the identity of authors, institutions, or research
results, independently screened the literature for inclusion and extracted the data.
A third individual was consulted in case of disagreement.
Key Study Factor
The key study factor was the effects on gingival health (referred to as periodontal
J Evid Base Dent Pract 2018: [176-177] health by the authors) after daily unsupervised home use of a powered or manual
toothbrush in populations with fixed orthodontic appliances. The experimental
1532-3382/$36.00
period was restricted to at least 4 weeks except for 1 study, which was 1 year in
ª 2018 Elsevier Inc. All
duration. Of the 9 included trials, 6 involved rotation-oscillation powered tooth-
rights reserved.
doi: https://doi.org/10.1016/ brushes, 1 used brushes with side-to-side action, 1 used an ionic toothbrush, and
j.jebdp.2018.03.011 1 investigated both oscillating and sonic heads.

176 Volume 18, Number 2


Main Outcome Measure
The main outcome measured was periodontal tissue inflam-
mation, which was assessed by a wide variety of different
indices among the various studies. These included Loe and
Silness gingival index, Eastman interdental bleeding index,
gingival bleeding index of Ainamo and Bay, bleeding on
probing, papillary bleeding score of Loesche, and the sulcus
bleeding index of Muhlemann and Son. Anatomic conditions
of the periodontal tissues that were assessed in 1 or more
studies included relative attachment loss, gingival hypertro-
phy, and pocket depth (1 study only).
Main Results
From an initial 1042 studies, 1005 were excluded based on title
and abstract. From these, reasons for exclusion were non-
randomization, only assessing plaque data, inadequate follow-
up, combining other interventions with toothbrushing, having
a cross-over design without adequate washout period, and not
providing adequate statistical information. The 9 remaining
full-text trials included in the systematic review were published
between 1997 and 2015 and included 434 total patients.
Conclusions
The authors commented that, in general, the quality of the
evidence was low and had an overall unclear risk of bias.
The 9 reviewed studies exhibited great variability in design
regarding toothbrush heads, mode of action of power
toothbrushes, and measurement indices. The conclusion
was that powered toothbrushes may promote gingival
health better than manual toothbrushes in orthodontic pa-
tients, with no brush type emerging as superior. However,
the authors also stated that the relevant scientific evidence
was inconclusive and remarked that better study standard-
ization, more studies with low bias risk and sufficient sample
size, and reporting of longer follow-ups are needed.
COMMENTARY AND ANALYSIS
This systematic review and meta-analysis searched 8 databases
and included 9 studies. Even with specified inclusion criteria,
these studies were heterogeneous in several parameters of
study design, and all were judged to have a low or unclear risk of
bias. This lack of standardization can have a deleterious effect
when analyzing data and drawing meaningful conclusions from
the combination of these vastly different studies.
The studies included in this review were small in scale,
having no more than 84 patients to as few as 20 patients.
Combining all powered toothbrush modes (sonic, rotation,
and ionic) in this review assumes that all powered brushes
work similarly. This assumption cannot be supported with
the data presented in the 9 included studies. In addition,
power toothbrush technology continuously advances, so
there is some question about the relevance of studies that
evaluate outdated technology that may no longer be
available in the marketplace.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Of the 9 studies included in this review, 5 were the basis of
the previous review published by Kaklamanos and Kalfas.1
The objective stated in the current review is “to appraise
the quality of the most up-to-date evidence”; however,
this review includes only 4 additional studies with only 2 of
those more recent than 2008. All were underpowered for
demonstrating significant differences among the groups.
The inclusion criteria specified for this review were quite
broad to the extent that 1 of the articles evaluated ionic
toothbrushes, a technology with an entirely different mode
of action from other brushes studied. Another included
article was a dissertation from 1999 that was non–peer
reviewed, unpublished, and difficult to access.
The inclusion of the study by Ho and Niederman2 is
questionable because it evaluated a sonic-powered tooth-
brush; sonics are purported to impact bacterial plaque in a
different fashion than oscillating-rotating power tooth-
brushes. The findings of Ho and Niederman were indeed
vastly different from those of any of the other included
studies, and these results skew the meta-analysis.
The conclusions made by the authors that power tooth-
brushes may promote gingival health better than manual
toothbrushes during orthodontic treatment is concerning
because the quality of the included studies was low, and this
conclusion appears largely based on the findings of 1 outlier
study. On the basis of the low-quality evidence presented,
clinicians should continue to look for high-quality evidence
to inform their recommendations regarding power tooth-
brushes during orthodontic treatment. The observation of
these authors regarding the need for standardization of
comparative studies, better experimental design, sufficient
sample size, and longer follow-up periods is supported.
REFERENCES
1. Kaklamanos EG, Kalfas S. Meta-analysis on the effectiveness of
powered toothbrushes for orthodontic patients. Am J Orthod
Dentofacial Orthop 2008;133:187.e1-187.e14.
2. Ho HP, Niederman R. Effectiveness of the Sonicare sonic tooth-
brush on reduction of plaque, gingivitis, probing pocket depth
and subgingival bacteria in adolescent orthodontic patients.
J Clin Dent 1997;8:815-9.
REVIEWERS
Terri Tilliss, RDH, MS, MA, PhD
Professor, Department of Orthodontics, University of Colo-
rado School of Dental Medicine, Aurora, CO, USA, Terri.
Tilliss@ucdenver.edu
Clifton M. Carey, PhD
Professor, Director of Translational Research, Department of
Craniofacial Biology, School of Dental Medicine, University
of Colorado, Aurora, CO, USA, clifton.carey@ucdenver.edu
June 2018 177