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

 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Main Outcome Measure Of the 9 studies included in this review, 5 were the basis of
The main outcome measured was periodontal tissue inflam- the previous review published by Kaklamanos and Kalfas.1
mation, which was assessed by a wide variety of different The objective stated in the current review is “to appraise
indices among the various studies. These included Loe and the quality of the most up-to-date evidence”; however,
Silness gingival index, Eastman interdental bleeding index, this review includes only 4 additional studies with only 2 of
gingival bleeding index of Ainamo and Bay, bleeding on those more recent than 2008. All were underpowered for
probing, papillary bleeding score of Loesche, and the sulcus demonstrating significant differences among the groups.
bleeding index of Muhlemann and Son. Anatomic conditions
The inclusion criteria specified for this review were quite
of the periodontal tissues that were assessed in 1 or more
broad to the extent that 1 of the articles evaluated ionic
studies included relative attachment loss, gingival hypertro-
toothbrushes, a technology with an entirely different mode
phy, and pocket depth (1 study only).
of action from other brushes studied. Another included
Main Results article was a dissertation from 1999 that was non–peer
From an initial 1042 studies, 1005 were excluded based on title reviewed, unpublished, and difficult to access.
and abstract. From these, reasons for exclusion were non-
The inclusion of the study by Ho and Niederman2 is
randomization, only assessing plaque data, inadequate follow-
questionable because it evaluated a sonic-powered tooth-
up, combining other interventions with toothbrushing, having
brush; sonics are purported to impact bacterial plaque in a
a cross-over design without adequate washout period, and not
different fashion than oscillating-rotating power tooth-
providing adequate statistical information. The 9 remaining
brushes. The findings of Ho and Niederman were indeed
full-text trials included in the systematic review were published
vastly different from those of any of the other included
between 1997 and 2015 and included 434 total patients.
studies, and these results skew the meta-analysis.
Conclusions
The conclusions made by the authors that power tooth-
The authors commented that, in general, the quality of the
brushes may promote gingival health better than manual
evidence was low and had an overall unclear risk of bias.
toothbrushes during orthodontic treatment is concerning
The 9 reviewed studies exhibited great variability in design
because the quality of the included studies was low, and this
regarding toothbrush heads, mode of action of power
conclusion appears largely based on the findings of 1 outlier
toothbrushes, and measurement indices. The conclusion
study. On the basis of the low-quality evidence presented,
was that powered toothbrushes may promote gingival
clinicians should continue to look for high-quality evidence
health better than manual toothbrushes in orthodontic pa-
to inform their recommendations regarding power tooth-
tients, with no brush type emerging as superior. However,
brushes during orthodontic treatment. The observation of
the authors also stated that the relevant scientific evidence
these authors regarding the need for standardization of
was inconclusive and remarked that better study standard-
comparative studies, better experimental design, sufficient
ization, more studies with low bias risk and sufficient sample
sample size, and longer follow-up periods is supported.
size, and reporting of longer follow-ups are needed.

COMMENTARY AND ANALYSIS REFERENCES

1. Kaklamanos EG, Kalfas S. Meta-analysis on the effectiveness of
This systematic review and meta-analysis searched 8 databases
powered toothbrushes for orthodontic patients. Am J Orthod
and included 9 studies. Even with specified inclusion criteria,
Dentofacial Orthop 2008;133:187.e1-187.e14.
these studies were heterogeneous in several parameters of
study design, and all were judged to have a low or unclear risk of 2. Ho HP, Niederman R. Effectiveness of the Sonicare sonic tooth-
bias. This lack of standardization can have a deleterious effect brush on reduction of plaque, gingivitis, probing pocket depth
when analyzing data and drawing meaningful conclusions from and subgingival bacteria in adolescent orthodontic patients.
J Clin Dent 1997;8:815-9.
the combination of these vastly different studies.

The studies included in this review were small in scale,

REVIEWERS
having no more than 84 patients to as few as 20 patients.
Terri Tilliss, RDH, MS, MA, PhD
Combining all powered toothbrush modes (sonic, rotation,
Professor, Department of Orthodontics, University of Colo-
and ionic) in this review assumes that all powered brushes
rado School of Dental Medicine, Aurora, CO, USA, Terri.
work similarly. This assumption cannot be supported with
Tilliss@ucdenver.edu
the data presented in the 9 included studies. In addition,
power toothbrush technology continuously advances, so Clifton M. Carey, PhD
there is some question about the relevance of studies that Professor, Director of Translational Research, Department of
evaluate outdated technology that may no longer be Craniofacial Biology, School of Dental Medicine, University
available in the marketplace. of Colorado, Aurora, CO, USA, clifton.carey@ucdenver.edu

June 2018 177