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Cochrane Database of Systematic Reviews Powered versus manual toothbrushing for oral health (Review) Powered versus manual toothbrushing for oral health (Review

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Cochrane Database of Systematic Reviews Powered versus manual toothbrushing for oral health (Review) Powered versus manual toothbrushing for oral health (Review
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  Cochrane Databaseof SystematicReviews Poweredversusmanualtoothbrushingfororalhealth(Review)  YaacobM,Worthington HV, DeaconSA,DeeryC,Walmsley AD,RobinsonPG,Glenny AM  YaacobM,Worthington HV, Deacon SA,Deery C,WalmsleyAD, Robinson PG,Glenny AM.Poweredversus manual toothbrushing for oralhealth. CochraneDatabaseofSystematicReviews  2014,Issue6.Art.No.:CD002281.DOI:10.1002/14651858.CD002281.pub3. www.cochranelibrary.com Poweredversus manual toothbrushing fororalhealth(Review) Copyright ©2014The CochraneCollaboration. Published byJohn Wiley& Sons,Ltd.  T A B L E O F C O N T E N T S 1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .6BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2223DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3month at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Analysis 1.2. Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Analysis 1.3. Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Analysis 1.4. Comparison 1 All powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Analysis 2.1. Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1to 3 month at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Analysis 2.2. Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at1 to 3 months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Analysis 2.3. Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Analysis 2.4. Comparison 2 Side to side powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at>3 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Analysis 3.1. Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 1 Plaquescores at 1 to 3 month at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Analysis 3.2. Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 2 Gingivitisscores at 1 to 3 months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Analysis 3.3. Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 3 Plaquescores at >3 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Analysis 3.4. Comparison 3 Counter oscillation powered toothbrushes versus manual toothbrushes, Outcome 4 Gingivalscores at >3 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Analysis 4.1. Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 1 Plaquescores at 1 to 3 month at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Analysis 4.2. Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 2 Gingivalscores at 1 to 3 months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Analysis 4.3. Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 3 Plaquescores at >3 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Analysis 4.4. Comparison 4 Rotation oscillation powered toothbrushes versus manual toothbrushes, Outcome 4 Gingivalscores at >3 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 iPowered versus manual toothbrushing for oral health (Review)Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.   Analysis 5.1. Comparison 5 Circular powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3month at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Analysis 5.2. Comparison 5 Circular powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1 to3 months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Analysis 6.1. Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3 months. 123 Analysis 6.2. Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 2 Plaque scores at >3 months at allsites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Analysis 6.3. Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 3 Gingivitis at 1 to 3 months. 124 Analysis 6.4. Comparison 6 Ionic toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at >3 months at allsites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Analysis 7.1. Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 1 Plaque scores at 1to 3 month at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Analysis 7.2. Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 2 Gingival scores at 1to 3 months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Analysis 7.3. Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 3 Plaque scores at >3months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Analysis 7.4. Comparison 7 Ultrasonic powered toothbrushes versus manual toothbrushes, Outcome 4 Gingival scores at>3 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Analysis 8.1. Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 1 Plaque scores at 1 to 3months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Analysis 8.2. Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 2 Gingival scores at 1 to 3months at all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Analysis 8.3. Comparison 8 Unknown or other action versus manual toothbrushes, Outcome 3 Gingival scores >3 monthsat all sites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130130 ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138 WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiPowered versus manual toothbrushing for oral health (Review)Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.  [Intervention Review] Powered versus manual toothbrushing for oral health Munirah Yaacob 1 , Helen V Worthington 2 , Scott A Deacon 3 , Chris Deery  4 , A Damien Walmsley  5 , Peter G Robinson 6 , Anne-MarieGlenny  21 DepartmentofPeriodontics, KulliyyahofDentistry,International IslamicUniversityMalaysia(IIUM),Kuantan, Malaysia. 2 CochraneOral Health Group, School of Dentistry, The University of Manchester, Manchester, UK.  3 South West Cleft Unit, Frenchay Hospital,Bristol,UK. 4 DepartmentofOralHealthandDevelopment,UniversityofSheffield,Sheffield,UK. 5 DepartmentofProstheticDentistry,School of Dentistry, Birmingham, UK.  6 School of Clinical Dentistry, University of Sheffield, Sheffield, UK Contact address: Helen V Worthington, Cochrane Oral Health Group, School of Dentistry, The University of Manchester, CouplandIII Building, Oxford Road, Manchester, M13 9PL, UK. helen.worthington@manchester.ac.uk . Editorial group:  Cochrane Oral Health Group. Publication status and date:  New search for studies and content updated (no change to conclusions), published in Issue 6, 2014. Review content assessed as up-to-date:  23 January 2014. Citation:  Yaacob M, Worthington HV, Deacon SA, Deery C, Walmsley AD, Robinson PG, Glenny AM. Powered versusmanual toothbrushing for oral health.  Cochrane Database of Systematic Reviews   2014, Issue 6. Art. No.: CD002281. DOI:10.1002/14651858.CD002281.pub3.Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. A B S T R A C T Background  Removing dental plaque may play a key role maintaining oral health. There is conflicting evidence for the relative merits of manualand powered toothbrushing in achieving this. This is an update of a Cochrane review first published in 2003, and previously updatedin 2005. Objectives To compare manual and powered toothbrushes in everyday use, by people of any age, in relation to the removal of plaque, the healthof the gingivae, staining and calculus, dependability, adverse effects and cost. Search methods  We searched the following electronic databases: the Cochrane Oral Health Group’s Trials Register (to 23 January 2014), the CochraneCentral Register of Controlled Trials (CENTRAL) ( The Cochrane Library   2014, Issue 1), MEDLINE via OVID (1946 to 23 January 2014), EMBASE via OVID (1980 to 23 January 2014) and CINAHL via EBSCO (1980 to 23 January 2014). We searched the USNational Institutes of Health Trials Register and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions wereplaced on the language or date of publication when searching the electronic databases. Selection criteria  Randomised controlledtrialsof atleastfour weeksof unsupervised poweredtoothbrushing versusmanual toothbrushing for oral healthin children and adults. Data collection and analysis  We used standard methodological procedures expected by The Cochrane Collaboration. Random-effects models were used providedthere were four or more studies included in the meta-analysis, otherwise fixed-effect models were used. Data were classed as short term(one to three months) and long term (greater than three months). 1Powered versus manual toothbrushing for oral health (Review)Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.  Main results Fifty-six trials met the inclusion criteria; 51 trials involving 4624 participants provided data for meta-analysis. Five trials were at low risk of bias, five at high and 46 at unclear risk of bias.There is moderate quality evidence that powered toothbrushes provide a statistically significant benefit compared with manual tooth-brushes with regard to the reduction of plaque in both the short term (standardised mean difference (SMD) -0.50 (95% confidenceinterval (CI) -0.70 to -0.31); 40 trials, n = 2871) and long term (SMD -0.47 (95% CI -0.82 to -0.11; 14 trials, n = 978). These resultscorrespond to an 11% reduction in plaque for the Quigley Hein index (Turesky) in the short term and 21% reduction long term. Bothmeta-analyses showed high levels of heterogeneity (I 2 = 83% and 86% respectively) that was not explained by the different poweredtoothbrush type subgroups. With regard to gingivitis, there is moderate quality evidence that powered toothbrushes again provide a statistically significant benefit when compared with manual toothbrushes both in the short term (SMD -0.43 (95% CI -0.60 to -0.25); 44 trials, n = 3345) and long term (SMD -0.21 (95% CI -0.31 to -0.12); 16 trials, n = 1645). This corresponds to a 6% and 11% reduction in gingivitis for the Löeand Silness index respectively. Both meta-analyses showed high levels of heterogeneity (I 2 = 82% and 51% respectively) that was notexplained by the different powered toothbrush type subgroups.The number of trials for each type of powered toothbrush varied: side to side (10 trials), counter oscillation (five trials), rotationoscillation (27 trials), circular (two trials), ultrasonic (seven trials), ionic (four trials) and unknown (five trials). The greatest body of evidence was for rotation oscillation brushes which demonstrated a statistically significant reduction in plaque and gingivitis at bothtime points.  Authors’ conclusions Poweredtoothbrushesreduceplaqueandgingivitismorethanmanualtoothbrushingintheshortandlongterm.Theclinicalimportanceof these findings remains unclear. Observation of methodological guidelines and greater standardisation of design would benefit bothfuture trials and meta-analyses.Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and only temporary. P L A I N L A N G U A G E S U M M A R Y Powered/electric toothbrushes compared to manual toothbrushes for maintaining oral healthReview question This review has been conducted to assess the effects of using a powered (or ’electric’) toothbrush compared with using a manualtoothbrush for maintaining oral health. Background  Good oral hygiene, through the removal of plaque (a sticky film containing bacteria) by effective toothbrushing has an important roleintheprevention ofgum disease andtooth decay.Dental plaqueistheprimary cause ofgingivitis (guminflammation) and isimplicatedin the progression to periodontitis, a more serious form of gum disease that affects the tissues that support the teeth. The build up of plaque can also lead to tooth decay. Both gum disease and tooth decay are the primary reasons for tooth loss.There are numerous different types of powered toothbrushes available to the public, ranging in price and mode of action. Differentpowered toothbrushes work in different ways (such as moving from side to side or in a circular motion). Powered toothbrushes alsovary drastically in price. It is important to know whether powered toothbrushes are more effective at removing plaque than manualtoothbrushes, and whether their use reduces the inflammation of the gums (gingivitis) and prevents or slows the progression of periodontitis. Study characteristics  Authors from the Cochrane Oral Health Group carried out this review of existing studies and the evidence is current up to 23 January 2014. It includes 56 studies published from 1964 to 2011 in which 5068 participants were randomised to receive either a poweredtoothbrush or a manual toothbrush. Majority of the studies included adults, and over 50% of the studies used a type of poweredtoothbrush that had a rotation oscillation mode of action (where the brush head rotates in one direction and then the other). 2Powered versus manual toothbrushing for oral health (Review)Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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