Manual versus powered toothbrushing for oral health

by Peter G Robinson

Manual versus powered toothbrushing for oral health (Review) Robinson P, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, Glenny AM, Shaw BC This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 1 http://www.thecochranelibrary.com Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER . . . . . . . . . . ABSTRACT . . . . . . . . . PLAIN LANGUAGE SUMMARY . BACKGROUND . . . . . . . OBJECTIVES . . . . . . . . METHODS . . . . . . . . . RESULTS . . . . . . . . . . DISCUSSION . . . . . . . . AUTHORS’ CONCLUSIONS . . ACKNOWLEDGEMENTS . . . REFERENCES . . . . . . . . CHARACTERISTICS OF STUDIES DATA AND ANALYSES . . . . . WHAT’S NEW . . . . . . . . HISTORY . . . . . . . . . . CONTRIBUTIONS OF AUTHORS DECLARATIONS OF INTEREST . SOURCES OF SUPPORT . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2 2 3 3 6 14 15 16 17 31 61 64 64 65 65 66 66 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. i [Intervention Review] Manual versus powered toothbrushing for oral health Peter Robinson1 , Scott A Deacon2 , Chris Deery3 , Mike Heanue4 , A Damien Walmsley5 , Helen V Worthington6 , Anne-Marie Glenny 7 , Bill C Shaw6 1 Department of Dental Public Health, School of Clinical 3 Department Dentistry, Shefﬁeld, UK. 2 South West Cleft Unit, Frenchay Hospital, Bristol, UK. of Paediatric Dentistry, Edinburgh Dental Institute, Edinburgh, UK. 4 Dental Surgery, Private Dental Practice, Shefﬁeld, UK. 5Department of Prosthetic Dentistry, School of Dentistry, Birmingham, UK. 6 Cochrane Oral Health Group, MANDEC, School of Dentistry, The University of Manchester, Manchester, UK. 7 Cochrane Oral Health Group, MANDEC, School of Dentistry, The University of Manchester, Manchester, UK Contact address: Peter Robinson, Department of Dental Public Health, School of Clinical Dentistry, University of Shefﬁeld, Claremont Crescent, Shefﬁeld, S10 2TA, UK. peter.g.robinson@shefﬁeld.ac.uk. Editorial group: Cochrane Oral Health Group. Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009. Review content assessed as up-to-date: 16 February 2005. Citation: Robinson P, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, Glenny AM, Shaw BC. Manual versus powered toothbrushing for oral health. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002281. DOI: 10.1002/14651858.CD002281.pub2. Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background Removing dental plaque may play a key role maintaining oral health. There is conﬂicting evidence for the relative merits of manual and powered toothbrushing in achieving this. Objectives To compare manual and powered toothbrushes in relation to the removal of plaque, the health of the gingivae, staining and calculus, dependability, adverse effects and cost. Search strategy We searched the Cochrane Oral Health Group Trials Register (to July 2004) and CENTRAL (The Cochrane Library 2004, Issue 2); MEDLINE (January 1966 to week 2 June 2004); EMBASE (January 1980 to week 2 2004) and CINAHL (January 1982 to week 2 June 2004). Manufacturers were contacted for additional data. Selection criteria Trials were selected for the following criteria: design-random allocation of participants; participants - general public with uncompromised manual dexterity; intervention - unsupervised manual and powered toothbrushing for at least 4 weeks. Primary outcomes were the change in plaque and gingivitis over that period. Data collection and analysis Six authors independently extracted information. The effect measure for each meta-analysis was the standardised mean difference (SMD) with 95% conﬁdence intervals (CI) using random-effects models. Potential sources of heterogeneity were examined, along with sensitivity analyses for quality and publication bias. For discussion purposes SMD was translated into percentage change. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1 Main results Forty-two trials, involving 3855 participants, provided data. Brushes with a rotation oscillation action removed plaque and reduced gingivitis more effectively than manual brushes in the short term and reduced gingivitis scores in studies over 3 months. For plaque at 1 to 3 months the SMD was -0.43 (95% CI: -0.72 to -0.14), for gingivitis SMD -0.62 (95% CI: -0.90 to -0.34) representing an 11% difference on the Quigley Hein plaque index and a 6% reduction on the Löe and Silness gingival index. At over 3 months the SMD for plaque was -1.29 (95% CI: -2.67 to 0.08) and for gingivitis was -0.51 (-0.76 to -0.25) representing a 17% reduction on the Ainamo Bay bleeding on probing index. There was heterogeneity between the trials for the short-term follow up. Sensitivity analyses revealed the results to be robust when selecting trials of high quality. There was no evidence of any publication bias. No other powered designs were as consistently superior to manual toothbrushes. Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and temporary. Authors’ conclusions Powered toothbrushes with a rotation oscillation action reduce plaque and gingivitis more than manual toothbrushing. Observation of methodological guidelines and greater standardisation of design would beneﬁt both future trials and meta-analyses. PLAIN LANGUAGE SUMMARY Manual versus powered toothbrushing for oral health When compared to manual toothbrushes, powered toothbrushes with a rotation oscillation action provide protection against gum inﬂammation in the long and short term and better plaque removal in the short term. Removing dental plaque by toothbrushing helps prevent gum inﬂammation (gingivitis). Toothbrushing with a ﬂuoride toothpaste prevents tooth decay. Powered toothbrushes simulate manual toothbrushing in different ways (such as moving side to side or circular motions). The review of trials found that only rotation oscillation (where brush heads rotate in one direction and then the other) is better than manual toothbrushes at removing plaque and reducing gum inﬂammation, and is no more likely to cause injuries to gums. Long- term beneﬁts of this for dental health are unclear. BACKGROUND Good oral hygiene (the removal of plaque) by effective toothbrushing has a key role in oral health. Dental plaque is the primary cause of gingivitis (gum inﬂammation) and is implicated in the progression to periodontitis (loss of periodontal attachment around the teeth) although the link between the two is complex and not well understood (Page 1997). Plaque is also one of the main causal factors in dental caries, although the evidence of a relationship between oral cleanliness and caries is not clear-cut (Addy 1986; Richardson 1977). When teeth are brushed with a ﬂuoride toothpaste ample evidence of a caries preventative effect is available, but this is due more to the effect of ﬂuoride than brushing per se (Chesters 1992). Effective toothbrushing depends on a number of factors including motivation, knowledge and manual dexterity. Powered brushes simulate the manual motion of toothbrushes with lateral and rotary movements of the brush head. More recently, there has been a progression towards rotary action brushes (van der Weijden1993a). Brushes which operate at a higher frequency of 2 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. vibration have also been introduced (Johnson 1994; Terezhalmy 1995b). Powered toothbrushes were ﬁrst introduced commercially in the early 1960s (Chilton 1962a; Cross 1962; Elliot 1963; Hoover 1962) and have become established as an alternative to manual methods of toothbrushing. In the UK the volume of sales of powered toothbrushes has nearly doubled each year between 1999 and 2001, increasing from 2% of total sales of all toothbrushes in 1999 to 7% in 2001 (Personal communication, R Davies 2002). One study has shown that 36 months after purchase, 62% of people were using their electric toothbrushes on a daily basis ( Stålnacke 1995). The compliance level was high and was unrelated to any social factors of the population studied. As the powered toothbrush is so popular the common question raised is which is better, the powered or manual? Types of interventions The toothbrushes included in the review were all forms of manual brushes and all forms of powered brushes. Trials instituting combined interventions, e.g. brushing combined with the use of mouthrinses or irrigation, were excluded. However, trials where participants were permitted to continue with their usual adjuncts to oral hygiene, such as ﬂossing, were included. Trials were excluded where the brushing intervention was carried out or was supervised by a professional within 28 days prior to a follow-up assessment. Trials of 28 days and over were eligible and a subgroup analysis was carried out on the duration of trials for the different outcome measurements. Powered toothbrushes were divided into seven groups according to their mode of action. Side to side action, indicates a brush head action that moves laterally side to side. Counter oscillation, indicates a brush action in which adjacent tufts of bristles (usually 6 to 10 in number) rotate in one direction and then the other, independently. Each tuft rotating in the opposite direction to that adjacent to it. Rotation oscillation, indicates a brush action in which the brush head rotates in one direction and then the other. Circular, indicates a brush action in which the brush head rotates in one direction. Ultrasonic, indicates a brush action where the bristles vibrate at ultrasonic frequencies (> 20 kHz). Ionic, indicates a brush that aims to impart an electrical charge to the tooth surface with the intent of disrupting the attachment of dental plaque. Unknown, indicates a brush action that the authors have been unable to establish based on the trial report or conﬁrm with the manufacturers. It was agreed that analysis of ﬁlament arrangement, orientation, size, shape and ﬂexibility, brush head size and shape along with presence or absence and characteristics of a timer would prove difﬁcult to deﬁne across time and brush types. OBJECTIVES To compare manual and powered toothbrushes in everyday use, by people of any age, in relation to: (1) removal of plaque; (2) inﬂammation of the gingivae; (3) removal of staining and calculus; (4) dependability and cost; (5) adverse effects. METHODS Criteria for considering studies for this review Types of studies The review is conﬁned to randomised controlled trials comparing manual and powered toothbrushes. It excludes trials conﬁned to comparisons between different kinds of powered brushes or those comparing different kinds of manual brushes. Cross-over trials were eligible. Split-mouth trials were excluded, as these were not considered representative of ’everyday use’. Types of outcome measures The primary outcome measures employed were quantiﬁed levels of plaque and/or gingivitis. Where possible values recorded on arrival at the assessment were used. If necessary, measures of gingivitis taken after participants had been instructed or permitted to brush their teeth at the assessment visit were used as it was assumed that toothbrushing would not affect gingivitis within such a short period. However, measures of plaque taken after participants had been instructed or permitted to brush their teeth at the assessment visit were not used. It was assumed that plaque scores achieved during toothbrushing under these circumstances would not reﬂect scores achieved in normal home use. 3 Types of participants Individuals of any age with no reported disability that might affect toothbrushing were included. Individuals wearing orthodontic appliances were also included. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Secondary outcome measures sought were levels of calculus and staining; dependability and cost of the brush used, including mechanical deterioration; and adverse effects such as hard or soft tissue injury and damage to orthodontic appliances and prostheses. The review is to be updated every 2 years using CENTRAL, the Cochrane Oral Health Group Trials Register, MEDLINE and EMBASE. Search methods for identiﬁcation of studies The search attempted to identify all relevant randomised controlled trials (RCTs) irrespective of language. For the original review we searched the following databases. • The Cochrane Oral Health Group Trials Register (to 22 August 2002) • The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2002, Issue 3) • MEDLINE (1966 to week 5 2002) • EMBASE (1980 to week 3 July 2002) • CINAHL (1982 to June 2002). An update search was undertaken on these databases as follows: • The Cochrane Oral Health Group Trials Register (to 17 July 2004) • The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2004, Issue 2) • MEDLINE (1966 to week 2 June 2004) • EMBASE (1980 to week 2 2004) • CINAHL (1982 to week 2 June 2004). For the identiﬁcation of trials included in, or considered for this review, detailed search strategies were developed for each database. These were based on the search strategy developed for MEDLINE but revised appropriately for each database to take account of differences in controlled vocabulary and syntax rules. The MEDLINE search strategy combined the subject search with phases one and two of the Cochrane Sensitive Search Strategy for RCTs (as published in Appendix 5b in the Cochrane Reviewers’ Handbook). The subject search used a combination of controlled vocabulary and free text terms and is published in full in Appendix 1. Details of search strategies applied to other databases are presented in Appendix 2; Appendix 3; Appendix 4 and Appendix 5. The following journals were identiﬁed as sources of frequently cited articles in the electronic search: Journal of Clinical Dentistry (9 citations); American Journal of Orthodontics and Dentofacial Orthopedics (8 citations); American Journal of Dentistry (8 citations); Journal of Clinical Periodontology (20 citations); Journal of Periodontology (17 citations); Journal of Dental Research (42 citations). As these journals are included in the Oral Health Group’s ongoing handsearching programme (www.ohg.cochrane.org), no further handsearching was undertaken. All references cited in the included trials were checked. Identiﬁed manufacturers were contacted and additional published or unpublished trial reports requested. Data collection and analysis Two authors independently reviewed the titles and abstracts identiﬁed in the search. If in the opinion of both authors an article clearly did not fulﬁl the deﬁned exclusion criteria it was considered ineligible. Full reports of all trials of possible relevance were obtained for assessment. On receipt of the full article, two authors assessed each study independently using speciﬁcally designed data extraction forms. Data extraction Data extraction was performed independently by all authors on 10 pilot articles. The authors reported back on the design of the data extraction forms and their interpretation of the inclusion and exclusion criteria along with their understanding of the outcome measures. On the basis of this feedback the data extraction forms were altered and the inclusion, exclusion and outcome measures redeﬁned to avoid misinterpretation. The ﬁnal data extraction protocol extracted the following information. (1) Bibliographic details of the study. (2) Funding source for the trial. (3) Inclusion eligibility. (4) Baseline characteristics of the participants in the study, including age, number of participants in the study and gender. Also, speciﬁc groups, such as dental students or orthodontic patients were noted, where mentioned. (5) Intervention characteristics including type of brush and its mode of action, duration of use and delivery of instructions. (6) Outcomes including plaque and gingivitis indices. A trial was considered to have adequately generated a random sequence of allocation, if it fully reported the type of allocation generation and it satisﬁed the CONSORT guidelines as true randomisation (http://www.consort-statement.org/). A trial was considered to have adequate blinding, if it stated that the method of outcome assessment did not allow the recording clinician to know to which group the participants had been allocated, with no other contradicting statement. Attrition was considered to have been adequately reported if there was a clear indication of how many withdrawals occurred in each group during the trial and an attempt made to give reasons why the withdrawals occurred. A trial was considered to have been funded by a brush manufacturer if it was reported that any material sponsorship from the manufacturer occurred, including the donation of brushes. It was considered unclear, if there was no statement on funding. A trial 4 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. was only considered to be unsponsored by a manufacturer if it clearly stated so. Trials were considered as ’short term’ or ’long term’. ’Short-term’ data include follow up between 28 days and 3 months. ’Long-term’ data include follow up beyond 3 months. Within each category of long term and short term, where a trial reported multiple end points, only the latest data were extracted. Data from trials that reported follow up before, and after 3 months were included in the pre- and post-3 month meta-analysis. This was the only circumstance when data from the same trial were considered twice. Many different indices of plaque and gingivitis were used across trials and some trials reported multiple indices. A frequencies table was prepared of the indices used and they were ranked based on common usage and simplicity. For plaque we extracted, where possible, data reported as the Turesky et al modiﬁcation of the Quigley-Hein plaque index of 1962 (Quigley 1962; Turesky 1970). For gingival inﬂammation we extracted where possible data reported as the gingival index of Löe and Silness (Löe 1963) or, if unavailable, bleeding on probing (Ainamo 1975). Data for ’Russell’s periodontal index’ were excluded because this index fails to distinguish between gingivitis and periodontitis (Russell 1967). Where available, data were extracted for whole mouth scores as opposed to part mouth scores. Where only part mouth scores were reported in a study, they were extracted and a sensitivity analysis carried out to consider their impact on the results of the review. Part mouth scoring was said to have occurred if plaque and or gingivitis were not recorded around all erupted teeth, except third molars. Completed data extraction forms were compared. Where there was disagreement between authors with regard to any part of the extraction details it was resolved by discussion between the authors and a note made on the data collection forms. Any disagreement, unresolved between the two authors, was settled by majority vote of the entire panel of six authors. Authors were contacted for clariﬁcation where necessary. Agreement between authors, concerning methodological quality, was assessed by calculating Kappa values for full mouth recording; adequate allocation concealment; adequate random number generation; adequate blinding of outcome assessor and adequate reporting of attrition. Numerical data extracted from the included trials were checked by a third author for accuracy and entered into Review Manager (RevMan). Data synthesis Choice of summary statistic and estimate of overall effect Different indices for plaque measure the same concept on different scales, with high correlation between the different indices. The same is true for gingivitis. As it is not possible to combine the results from different indices, the effects were expressed as standardised values, which have no units, before combining. The standardised mean difference (SMD) was therefore calculated along with the appropriate 95% conﬁdence intervals (CI) and was used as the effect measure for each meta-analysis (Deeks 2001). Statistical values such as SMD have no inherent clinical meaning. Therefore we back-translated them using the clinical indices from a study where the difference was similar to the SMD. Such examples are given in the discussion. Random-effects models were performed throughout. Assessment of heterogeneity and investigation of reasons for heterogeneity Methodological quality Quality assessment was carried out independently and in duplicate at the same time as data were extracted. Particular emphasis was placed on allocation concealment ranked using the Cochrane criteria: Grade A: Adequate, B: Unclear, C:Inadequate, and D: Not used. Consideration was also given to: (1) Generation of randomisation sequence (2) A priori calculation of sample size (3) Blind outcome assessment (4) Comparability of groups at baseline (5) Duration of study (6) Attrition bias (7) Reliability tests for outcome measures. Heterogeneity was assessed by inspection of a graphical display of the estimated treatment effects from the trials along with their 95% CI and by Cochran’s test for heterogeneity undertaken before each meta-analysis. Subgroup analyses were undertaken for assessments based on full mouth recording versus those based on a partial recording and to examine the effects of concealed allocation, randomisation generation and blind outcome assessment on the overall estimates of effect for important outcomes. Cross-over trials It was planned to combine the data from cross-over trials with that of similar parallel group trials, using the techniques described by Elbourne et al (Elbourne 2002). Due to insufﬁcient data this was not possible. Investigation of publication and other biases A funnel plot (plots of effect estimates versus the inverse of their standard errors) was drawn. Asymmetry of the funnel plot may indicate publication bias and other biases related to sample size, though it may also represent a true relationship between trial size 5 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. and effect size. A formal investigation of the degree of asymmetry was performed using the method proposed by Egger et al (Egger 1997). A further method proposed by Begg and Mazumdar which tests for publication bias by determining if there is a signiﬁcant correlation between the effect estimates and their variances was also carried out (Begg 1994). Both methods were carried out using Stata version 7.0 (Stata Corporation, USA) using the program Metabias. RESULTS Description of studies See: Characteristics of included studies; Characteristics of excluded studies. In the original review the search identiﬁed 354 trials of which 139 were considered to be ineligible from the information provided in the title or abstract. Full articles were obtained for the remaining 215. From the full articles 152 trials proved ineligible. From the abstracts and full articles 29 trials had insufﬁcient detail to be able to convincingly allocate them to the category of included or excluded trials. Thirty-six trials were eligible. Of these eligible Table 1. Summary of characteristics of excluded studies Reason for exclusion Less than 28 days Not powered versus manual Not RCT trials, ﬁve cross-over and two parallel trials provided insufﬁcient information for the data to be used in a meta-analysis, and were excluded. The authors of 36 trials with insufﬁcient information were contacted and asked to provide the missing details required to include or exclude the data. Twenty-nine trials fulﬁlled all inclusion criteria and had results that could be entered for metaanalysis. In the update, an additional 10 trials were identiﬁed as clearly meeting the inclusion criteria (Galgut 1996; Garcia-Godoy 2001; Hickman 2002; Pucher 1999; Sharma 2000; Soparkar 2000; Sowinski 2000; Toto 1966; Van Swol 1996; Zimmer 2002). For three further trials, identiﬁed in the original search, information was received from the authors allowing a judgment to be made on their inclusion (Haffajee 2001a; Lapiere unpublished; Singh unpublished). A total of 42 trials are included in this update. A primary reason for the exclusion of each study is given in the Characteristics of excluded studies table. Many trials were ineligible for more than one reason. Trials or abstracts which proved to be duplicates of included studies are tabulated here, but entered in the included study references list, as such. For trials where authors had been contacted for further information and where no reply was received after 3 months, the study was considered ineligible for insufﬁcient data available. Should the required data be supplied such trials will be addressed in the next review. A summary of the reasons for exclusion is given in Additional Table 1. Number (n = 245) 93 65 27 Author contacted for more information, no reply after 3 months 15 Split mouth Duplicate abstract or study Potential high for compromised tooth brushing efﬁcacy 15 1 8 Cross-over trial, authors contacted for more information, no reply 5 after 3 months Outcomes not under consideration Combined intervention 9 9 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 6 Table 1. Summary of characteristics of excluded studies (Continued) No movement of brush head Laboratory study Teeth brushed by another person Not teeth Not human Abstract only Of the 42 included trials, 30 were conducted in North America ( Baab 1989; Barnes 1993; Cronin 1998; Dentino 2002; Emling 1991; Forgas-B 1998; Garcia-Godoy 2001; Glass 1965; Haffajee 2001a; Ho 1997; Johnson 1994; Khocht 1992; Lobene 1964a; O’Beirne 1996; Pucher 1999; Sharma 2000; Singh unpublished; Soparkar 1964; Soparkar 2000; Sowinski 2000; Terezhalmy 1995a; Toto 1966; Tritten 1996; Van Swol 1996; Walsh 1989; Warren 2001; Wilson 1993; Yankell 1996; Yankell 1997; Yukna 1993b); 11 in Europe (Ainamo 1997; Clerehugh 1998; Galgut 1996; Heasman 1999; Hickman 2002; Lapiere unpublished; Lazarescu 2003; McAllan 1976; Stoltze 1994; van der Weijden 1994; Zimmer 2002) and one in Israel (Stabholz 1996). Three trials were unpublished (Lapiere unpublished; Lazarescu 2003; Singh unpublished). The remainder were published between 1964 and 2004; four in the 1960s; one in the 1970s; two in the 1980s; 23 in the 1990s and eight since 2000. At least 28 were funded in some part by the manufacturer of one of the powered toothbrushes, the remainder were unclear about sponsorship. The combined total number of participants included in the trials was 3967. The number of patients reported lost to follow up was 309 (7.8%). Characteristics of participants The characteristics of participants in each study are noted in the Characteristics of included studies table and in Additional Table 2. Out of the 42 eligible trials the four most frequently stated inclusion criteria were adults (79% of trials), no relevant medical history (62%), a stated minimum number of teeth (55%) and a criterion related to gingival or periodontal health or plaque at baseline (43%). Exclusion criteria for included trials were noted and summarised in Additional Table 3. 2 11 1 1 1 1 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 7 Table 2. Summary of inclusion criteria categories within included studies Inclusion criteria Exclusion criteria related to medical history Adults Minimum number of teeth Minimum periodontal baseline measures Participants recruited from dental clinics Concurrent ﬁxed orthodontic treatment Some participants aged less than 16 years Volunteer university students Dental students Number (n = 42) 29 34 24 18 11 5 9 3 1 Table 3. Summary of exclusion criteria categories within included studies Exclusion criteria Pregnancy or lactation Previous use of powered toothbrushes Patients undergoing orthodontic treatment Previous periodontal treatment Dental students Cervical restorations Smoking Maximum periodontal measure Number (n = 42) 5 4 6 2 2 1 1 4 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 8 Characteristics of interventions The powered toothbrushes, included: Braun, Interplak, Braun Plaque Remover with OD5 head, Braun Oral B 3D, Braun Oral B D9, PlaK Trac, Ultrasonex, GEC, Braun Oral B D7, Philips Jordan HP 735, Philips HP 550,Sonicare ultrasonic, Philips Sonicare, Epident, Braun Oral B D5, Philips 550, Touchtronic Teledyne Aqua Tec, Ronson, Dominion, Pulse Plaque Remover, Broxodent, Plaq and White, LPA/Broxo, Braun D17, Rowenta Dentiphant, Rowenta, Plaque Dentacontrol Plus, Sangi Co Electronic, Braun Oral B D10, Braun Oral B D15 Plaque Remover, Braun Plaque Remover 3D with orthodontic head, Hukuba ionic, Colgate Actibrush, HyG ionic, unspeciﬁed ionic, Ultra Sonex Ultima, Sunbeam cordless. These are summarised in Additional Table 4. Table 4. Summary of toothbrush modes of action, number of trials and participants Mode of action Side to side Trial ID Number of trials n - attrition 627 Glass 1965, Ho 1997, Johnson 8 1994, Lobene 1964, O’Beirne 1996, Tritten 1996, Walsh 1989, Yankell 1997 Baab 1989, Khocht 1992, Stabholz 5 1996, Wilson 1993, Yukna 1993 Ainamo 1997, Barnes 1993, Clere- 18 hugh 1998, Cronin 1998, Dentino 2002, Heasman 1999, Lazarescu unpublished, Stoltze 1994, Warren 2001, Yankell 1997, van der Weijden 1994, Haffajee 2001a, Lapiere unpublished, Hickman 2002, Sharma 2000, Soparkar 2000, Sowinski 2000, Garcia-Godoy 2001 Khocht 1992, McAllan 1976, 3 Yankell 1996 Forgas Brockman 1998, 3 Terezhalmy 1995, Zimmer 2002 Emling 1991, Soparkar 1964, Toto 4 1966, Singh unpublished Van Swol 1996, Pucher 1999, 3 Galgut 1996 Counter oscillation 224 Rotation oscillation 1444 Circular 168 Ultrasonic 171 Unknown 870 Ionic 179 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 9 Powered toothbrush, mode of action The powered toothbrushes were subdivided into seven groups according to their mode of action. Side to side action Philips Sonicare and Sonicare brushes (Sonicare c/o Philips Oral Healthcare, 35301 SE Center Street, Snoqualmie, WA 98065; http://www.sonicare.com/); Philips 550 (Philips Jordan, P.O. Box 324, 5500 AH Veldhoven, The Netherlands; http://www.philips-jordan.com/). Counter oscillation Interplak brush (Interplak Conair Corporation, 1 Cummings Point Road, Stamford, CT 06904; http://www.conair.com/ products/). Rotation oscillation Braun Oral B 3D, D17, Plaque Remover with OD5 head, Oral B D9, Oral B D7, Oral B D5, Oral B D10, Braun Plaque Remover 3D with orthodontic head, Braun Oral B D15 Plaque Remover, (Braun Oral B Consumer Services, 1 Gillette Park, South Boston, MA; http://www.oralb.com/); Philips Jordan HP 735, Philips HP 550 (Philips Jordan P.O. Box 324, 5500 AH Veldhoven, The Netherlands; http://www.philips-jordan.com/); Colgate Actibrush (Consumer Affairs, Colgate-Palmolive (UK) Limited, Guildford Business Park, Middleton Road, Guildford, Surrey GU2 8JZ UK; http://www.colgate.co.uk/contact/index.shtml). Circular Rowenta Dentiphant, Rowenta, Plaque Dentacontrol Plus (Rowenta Werke GmbH, Franz Alban, Stützer, Germany; http:// www.products.rowenta.de/row/index.html); Teledyne Aqua Tech brushes (Corporate Headquarters 12333 West Olympic Boulevard Los Angeles, CA 90064; http:// www.waterpik.com/oralhealth/ ). Ultrasonic Ultrasonex brush, Ultra Sonex Ultima (Salton-Maxim 1801 N. Stadium Boulevard, Columbia, MO 65202; http://www.saltonmaxim.com/salton/ultrasonex/ultrasonex.asp). Ionic Sangi Co Electronic (Tokyo), Hukuba ionic and the HyG ionic (Hukuba Dental Corporation, 914-1 Nazukari, Nagareyama, Chiba, 270-01 Japan). Unknown Some companies are no longer trading or complete details of the relevant toothbrushes are not easily found. The following toothbrushes fall into this latter category: PlaK Trac, GEC, Epident, Touchtronic, Ronson, Dominion, Broxodent, Plaq and White, LPA/Broxo, Sunbeam cordless. The names and addresses of the manufacturers have changed over the years and those quoted above are correct at the time of the present review. Some of the trials were conducted when another company made the powered toothbrush. Eight trials including 627 participants at the end of the trial compared manual brushing versus side to side powered toothbrushing. Five trials provided data on 224 participants at the end of the trial compared manual brushing versus counter oscillating toothbrushing. Eighteen trials with 1444 participants at the end of the trial compared manual brushing versus rotation oscillation powered brushing. Three trials including 168 participants at the end of the trial compared manual brushing versus circular powered brushing and three trials of 171 participants at the end of the trial compared manual brushing versus ultrasonic powered brushing. Three trials with 179 participants at the end of the trial compared manual brushing versus ionic brushing. Four trials with 870 participants at the end of the trial compared manual brushing and a powered toothbrush with an unknown action. Summary of trials by toothbrush action See Additional Table 4. The trials that compared manual with a side to side action powered brush were: (Glass 1965; Ho 1997; Johnson 1994; Lobene 1964a; O’Beirne 1996; Tritten 1996; Walsh 1989; Yankell 1997). Counter oscillation: ( Baab 1989; Khocht 1992; Stabholz 1996 (not included in meta-analysis); Wilson 1993; Yukna 1993b). Rotation oscillation: (Ainamo 1997; Barnes 1993; Clerehugh 1998; Cronin 1998; Dentino 2002; Garcia-Godoy 2001; Haffajee 2001a; Heasman 1999; Hickman 2002; Lapiere unpublished; Lazarescu 2003; Sharma 2000; Soparkar 2000; Sowinski 2000; Stoltze 1994; van der Weijden 1994; Warren 2001; Yankell 1997). Circular: (Khocht 1992; McAllan 1976; Yankell 1996). Ultrasonic: (Forgas-B 1998; Terezhalmy 1995a; Zimmer 2002). Ionic: (Galgut 1996; Pucher 1999; Van Swol 1996) and unknown (Emling 1991; Singh unpublished; Soparkar 1964; Toto 1966). Characteristics of outcome measures Thirty-four trials (2295 participants at the end of the trial) reported plaque at 1 to 3 months and 10 trials (705 participants at the end of the trial) at longer than 3 months. Thirty-nine (2870 participants at the end of the trial) reported gingivitis at 1 to 3 months and 12 (1372 participants at the end of the trial) at greater than 3 months. Twenty-eight trials recorded whole mouth scores for plaque and gingivitis; ﬁve trials recorded part mouth scores for both variables. One trial recorded part mouth scores for plaque and whole mouth scores for gingivitis and four trials recorded whole mouth scores for plaque and part mouth scores for gingivitis. Two trials reported only plaque data, one for whole mouth scores and one for part mouth scores. One trial reported part mouth scores for gingivitis only.One study reported for both plaque and gingivitis but it has not been possible to ascertain whether the data relate to part or all 10 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. of the mouth (Singh unpublished). Risk of bias in included studies The agreement between the authors was generally good with Kappa values for adequacy of allocation concealment 0.49, adequate outcome assessor blinding 0.72, adequacy of reporting and handling of attrition 0.70 and mention of manufacturer funding 1.00. Selection bias The generation of randomisation sequence was adequate for 15 (35.7%) of the 42 trials, inadequate for two trials (4.8%) and unclear for 25 trials (59.5%). The concealment of allocation was adequate for 16 trials (38.1%), unclear for 24 (57.1%) and inadequate for 2 (4.8%). Detection bias The outcome assessor was adequately blinded in 38 trials (90.5%). The adequacy of blinding was unclear in ﬁve trials (7.1%). Blinding was not undertaken in one trial (2.4%). Attrition bias Intention-to-treat analysis was carried out in three trials (7.1%), unclear in two trials (4.8%) and not undertaken in 37 trials (88.1%). The reported drop-out rate was 8.0%. Trials with follow up of less than 3 months had a drop-out rate of 5.9%. Trials with follow up of greater than 3 months had a drop-out rate of 10.6%. Sponsorship Funding by a manufacturer of at least one of the brushes under investigation was stated in 28 (67%) of the trials and unclear in 14 (33%). Counter oscillation powered toothbrushes versus manual (Comparison 2 Outcomes 2.1 to 2.4) There was no evidence that powered toothbrushes whose action was counter oscillation were more effective than manual brushes for the removal of plaque or reduction of gingivitis with the exception of being associated with less plaque in the long term, where the SMD was -0.63 (95% conﬁdence interval (CI): -1.11 to 0.14). There were four trials included in the meta-analysis for 1 to 3 month plaque, four for 1 to 3 month gingivitis and only two trials included in both the meta-analyses for measures after 3 months. Rotational oscillation powered toothbrushes versus manual (Comparison 3 Outcomes 3.1 to 3.4) This comparison contained the greatest number of trials, with 15 trials included in the meta-analyses for early plaque, 16 for early gingivitis, and three trials included in the long-term comparison for plaque and four trials for long-term gingivitis. To assist in the appreciation of the size of the beneﬁt of the rotation oscillation brushes, SMDs have been converted to equivalent values in commonly used plaque and gingivitis indices. Brushes that worked with a rotation oscillation action removed more plaque and reduced gingivitis more effectively than manual brushes in the short term. For plaque at 1 to 3 months the SMD was -0.43 (95% CI: -0.72 to -0.14), for gingivitis SMD -0.62 (95% CI: -0.90 to -0.34). These differences are the approximate equivalent of a reduction of 0.27 or 11% on the Quigley Hein plaque index and a reduction of 0.06 or 6% on the Löe and Silness gingival index. At over 3 months the SMD for plaque was -1.29 (95% CI: -2.67 to 0.08). Brushes of this design reduced gingivitis scores in studies over 3 months. SMD for gingivitis -0.51 (95% CI: -0.76 to -0.25). This difference is the equivalent of a 17% reduction on the Ainamo Bay bleeding on probing index. There was considerable heterogeneity between the trials in the metaanalyses for the short-term follow up, which is reported later in this section. Circular powered toothbrushes versus manual (Comparison 4 Outcomes 4.1 to 4.4) There was no evidence that brushes with a circular action removed plaque or reduced gingivitis more effectively than manual brushes in either time period. Three trials were included in both these analyses for early plaque and gingivitis evaluation, and only one trial in each of the meta-analyses for longer follow up. Ultrasonic toothbrushes versus manual (Comparison 5 Outcomes 5.1 to 5.4) Ultrasonic brushes reduced gingivitis in studies of less than 3 months. SMD was -0.64 (95% CI: -1.04 to -0.24). No other signiﬁcant differences were noted between the effects of manual and ultrasonic brushes. There were three trials for each of the meta11 Effects of interventions As mentioned in the data synthesis section of the methods of the review, the differences in plaque and gingivitis reduction between the powered and manual brushes were expressed as standardised mean differences (SMDs) for both short-term and long-term studies. Signiﬁcant differences in SMDs are reported below. Side to side powered toothbrushes (Comparison 1 Outcomes 1.1 to 1.4) There was no statistically signiﬁcant difference between powered toothbrushes whose action was side to side and manual brushes with regard to the removal of plaque or reduction of gingivitis for both time periods. Six trials compared side to side powered brushes included in the meta-analysis for 1 to 3 month plaque, eight for 1 to 3 month gingivitis and only two trials included in both the meta-analyses for measures after 3 months. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. analyses for the short-term assessments of plaque and gingivitis, and one trial in both long-term meta-analyses. Unknown versus manual (Comparison 6 Outcomes 6.1 to 6.4) The analyses for plaque in the short term and for gingivitis in the long term each included one trial but neither analysis indicated a beneﬁt from the powered brush. The analysis for brushes of unknown action in short-term studies of gingivitis comprised 3 trials. The effect was signiﬁcant as the SMD was -0.38 (95% CI: -0.59 to -0.17). Ionic toothbrushes versus manual (Comparison 7 Outcomes 7.1 to 7.4) Three trials were included in the analysis for ionic brushes. All three studies were included in the short-term analysis of plaque and two for gingivitis. There was one long-term study of plaque and gingivitis. The short-term analyses indicated no effect on plaque or gingivitis. The analysis of the data from the single long-term trial showed a difference in favour of the ionic toothbrush on both plaque (SMD -1.01(95% CI: -1.53 to -0.49)) and gingivitis (SMD -0.78 (95% CI: -1.29 to -0.27)). Investigation of heterogeneity The heterogeneity in the short-term meta-analyses comparing rotation oscillation powered and manual brushing for both plaque and gingivitis was caused by one study with exceptionally low standard deviations for all indices (Stoltze 1994). Sensitivity analyses Sensitivity analyses were conducted to test whether the assumptions involved in the design of this review affected the ﬁndings. These analyses were undertaken by repeating the meta-analyses in the following cases: where a full mouth index had been used, where adequate concealment of randomisation occurred, where there was adequate generation of randomisation sequence, where there was blinding of the outcome assessor, if the trial was funded by a manufacturer, with adequate information about attrition and for trials that were not restricted to participants only wearing ﬁxed orthodontic appliances. Sensitivity analyses were limited to the data on rotational oscillation powered toothbrushes (Comparison 3 Outcomes 3.1 and 3.2) because they were the ones that showed signiﬁcant effects and contained the greatest number of trials. All but two of the revised meta-analyses yielded similar effect estimates to the overall estimates, indicating that the results are robust and not distorted by the lesser quality trials (Additional Table 5). Only six trials on plaque adequately generated and concealed the allocation sequence and the revised analysis of these six studies did not detect a beneﬁt with the powered brushes. Table 5. Sensitivity analyses of trials of rotation oscillation versus manual (1-3 months) Group selected All studies Index Number studies 15 of SMD (95%CI) Effect P-value Het. Chi2 Het. P-value I2 (%) plaque -0.43 (-0.72 to 0.004 -0.14) -0.46 (-0.77 to 0.003 -0.16) -0.06 (-0.51 to 0.81 0.39) 81.81 < 0.001 82.9 Full mouth plaque recording Adequate con- plaque cealed allocation Adequate ran- plaque dom number generation Outcome as- plaque sessor blinded Adequate re- plaque porting of attrition 14 78.84 < 0.001 83.5 6 27.72 < 0.001 82.0 6 -0.07 (-0.51 to 0.75 0.37) 28.49 < 0.001 82.4 13 -0.38 (-0.67 to 0.010 -0.09) -0.45 (-0.79 to 0.010 -0.11) 63.98 < 0.001 81.2 13 80.17 < 0.001 85.0 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 12 Table 5. Sensitivity analyses of trials of rotation oscillation versus manual (1-3 months) (Continued) Manufacturer funded plaque 9 -0.39 (-0.80 to 0.06 0.02) -0.46 (-0.76 to 0.003 -0.16) 61.52 < 0.001 87.0 Trials plaque not limited to patients wearing ﬁxed orthodontic appliances 14 78.61 < 0.001 83.5 All studies gingivitis 16 -0.62 (-0.90 to < 0.001 -0.34) -0.70 (-1.01 to < 0.001 -0.40) -0.38 (-0.66 to 0.007 -0.11) 83.96 < 0.001 82.1 Full mouth gingivitis recording Adequate con- gingivitis cealed allocation Adequate ran- gingivitis dom number generation Outcome as- gingivitis sessor blinded Adequate re- gingivitis porting of attrition Manufacturer funded gingivitis 14 75.99 < 0.001 82.9 6 10.71 0.06 53.3 7 -0.40 (-0.64 to < 0.001 -0.17) 11.32 0.08 47.0 14 -0.54 (-0.79 to < 0.001 -0.30) -0.67 (-0.99 to < 0.001 -0.34) 52.34 < 0.001 75.2 14 82.43 < 0.001 84.2 10 -0.69 (-0.98 to < 0.001 -0.40) -0.70 (-1.01 to < 0.001 -0.39) 37.99 < 0.001 76.3 Trials gingivitis not limited to patients wearing ﬁxed orthodontic appliances 14 76.77 < 0.001 83.1 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 13 Publication bias Publication bias was assessed for the meta-analyses for rotational oscillation powered toothbrushes versus manual for the 1 to 3 month assessments. The funnel plots for each appeared symmetric with no evidence of bias for either plaque or gingivitis using the Egger (weighted regression) method (P = 0.78, 0.52 respectively), or using the Begg (rank correlation) method (P = 0.72, 0.41). Secondary outcomes Cost None of the included trials reported on the relative costs of manual compared with powered toothbrushes. Reliability One trial reported a mechanical failure of one of the 48 powered toothbrushes used (Clerehugh 1998) and one trial reported mechanical failure in four of 20 powered brushes (Yukna 1993b). No other mechanical failures were reported. Calculus Therefore, of the original 42 studies, there were ﬁve that described differences in tissue trauma between participants using manual and powered toothbrushes. One trial reported ﬁve cases of gingival abrasion in the manual and one case of abrasion in the powered group (Tritten 1996), another reported 12 cases of gingival abrasion in the manual and ﬁve cases of gingival abrasion in the powered group (van der Weijden 1994). One trial reported seven soft tissue abnormalities in six participants in the manual group and 10 abnormalities in seven participants in the powered group (Johnson 1994). In the trial by Yukna et al (Yukna 1993b) four cases of abrasion were reported in the powered toothbrush group and one in the manual group. Khocht (Khocht 1992) reported soft tissue changes in four participants using the manual toothbrush, six using the experimental powered toothbrush and one participant using a control powered toothbrush. These soft tissue changes were seen as transient irritations that were possibly/probably due to the product. DISCUSSION We brush our teeth for many reasons: to feel fresh and conﬁdent; to have a nice smile; to avoid bad breath and to avoid disease. The selection of one’s toothbrush is largely a matter of personal preference, affordability, availability and professional recommendation. Powered toothbrushes may have a particular appeal to some because they represent a newer ’high tech’ solution to an everyday task. This systematic review has found that powered toothbrushes with a rotation oscillation action removed plaque and reduced gingivitis more than manual brushes in the short term and of gingivitis in the long term. In the course of this revision we questioned the inclusion of one study of plaque over 3 months. Excluding this study does not substantially change our estimate of the treatment effect. However, because there are fewer studies in the analysis the 95% conﬁdence intervals are wider (-2.67, 0.08). The ﬁndings of this analysis are no longer statistically signiﬁcant although the upper limit of the 95% conﬁdence interval only just exceeds equivalence. The line of equivalence is a reference point on the Forest plots. If the conﬁdence intervals include the line of equivalence, then it is more likely that any apparent differences between the effects of the brushes can be explained by the play of chance. In this case, the conﬁdence interval was close to the line of equivalence and almost met our threshold for accepting that there was a beneﬁt from the powered brush. Other forms of powered brushes produced a less consistent reduction of plaque and gingivitis. Few data were reported on the costs or reliability of the brushes or the side effects of their use. When reported, injuries to the gums 14 Three trials (Dentino 2002; Glass 1965; van der Weijden 1994) reported on calculus, two reporting that there was no signiﬁcant difference between the brush types (Glass 1965; van der Weijden 1994) and one reporting that, compared to the manual brush, the powered brush group showed a signiﬁcant favourable difference in the accumulation of calculus at 6 months P = 0.0078 (Dentino 2002). Stain Three trials reported that there was no difference in the degree of staining on the teeth between the brush types (Dentino 2002; Glass 1965; Walsh 1989). Adverse events - Tissue trauma 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. Eight trials did not report on adverse events (Haffajee 2001a; Ho 1997; Lazarescu 2003; Lobene 1964a; McAllan 1976; Soparkar 1964; Van Swol 1996; Zimmer 2002). Of the 34 that did report on adverse events, 23 reported no trauma to soft and/or hard tissues (Ainamo 1997; Clerehugh 1998; Dentino 2002; Emling 1991; Forgas-B 1998; Galgut 1996; Garcia-Godoy 2001; Glass 1965; Heasman 1999; Hickman 2002; Pucher 1999; Sharma 2000; Singh unpublished; Soparkar 2000; Sowinski 2000; Stabholz 1996; Stoltze 1994; Toto 1966; Walsh 1989; Warren 2001; Wilson 1993; Yankell 1996; Yankell 1997) and six reported no signiﬁcant differences between powered and manual toothbrushes, or that tissue trauma was negligible (Baab 1989; Barnes 1993; Cronin 1998; Lapiere unpublished; O’Beirne 1996; Terezhalmy 1995a). Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. were minor and transient. Randomised controlled trials may not be the best research design for investigating these adverse outcomes. Expert groups have suggested that powered toothbrushes are safe if used correctly but further research is required in these areas ( Lang 1998). There is overwhelming evidence that toothbrushing reduces gingivitis (Lang 1973). It may prevent periodontitis and certainly prevents tooth decay if carried out in conjunction with ﬂuoride toothpaste. These beneﬁts occur whether the brush is manual or powered and the results of this review do not indicate that toothbrushing is only worthwhile with a powered toothbrush. As mentioned in the results section, standardised mean differences (SMDs) may be converted to the corresponding values of particular clinical indices. The plaque scores in short-term trials of rotation oscillation brushes was -0.43. Using this level of effectiveness as an example, in the trial by Cronin (Cronin 1998) a similar standardised mean difference (-0.45) corresponded to a mean difference in the Turesky modiﬁcation of the Quigley Hein index of 0.27. The mean plaque score among those using manual brushes in the trial by Cronin was 2.55 and thus the difference is 11%. For gingival scores the SMD in short-term trials of rotation oscillation brushes was -0.62. Again, using this level of effectiveness, in the trial by Cronin (Cronin 1998) the SMD of -0.54 corresponded to a mean difference in the Löe and Sillness gingival index of 0.06. The mean gingival index score for those using manual brushes in the trial was 0.97 and thus the difference is 6%. The same approach can be used to assess the effect of rotation oscillation powered toothbrushes on long-term reductions in gingivitis, and indicates beneﬁts of 17%. Had a weighted mean difference method been used for pooling the data rather than a standardised mean difference, similar results and conclusions would have been reached . Doubt persists in what level of plaque removal and reduction in gingivitis will result in clinically signiﬁcant improvements in periodontal health. The results of the review can be related to destructive periodontal disease (periodontitis) only with some difﬁculty. Some authorities have advocated the use of arbitrary thresholds to make superiority claims for a speciﬁc product. For example, Imrey has proposed that a product cannot be claimed to be superior unless it provides a 20% improvement in performance (not the case for any types of brush in this review, in terms of long-term plaque removal) (Imrey 1992; Imrey 1994). However, other authors have criticised the use of arbitrary thresholds and prefer a threshold for clinical signiﬁcance to be decided in advance and selected on clinical grounds ( D’Agostino 1992). Many factors are associated with the occurrence of periodontitis including plaque, tobacco use and individual medical factors. Periodontitis takes many years to develop and the trials have much shorter follow up. There is no compelling evidence that plaque and gingivitis are reliable proxies for long-term destructive disease and it is difﬁcult to estimate a clinical threshold for signiﬁcant plaque reduction. We conclude that rotation oscillation brushes provide reductions for plaque removal but the clinical importance of these reductions cannot be assessed. With 27 analyses in this study it is possible that some may appear signiﬁcant by the play of chance. Isolated analyses appear to show a beneﬁt for counter oscillation brushes against plaque in long-term studies, for ultrasonic brushes and those of unknown action against gingivitis in short-term studies and in one long-term study of ionic brushes against plaque and gingivitis. In each case these outcomes were the only ones associated with the use of these brushes. It is difﬁcult to explain this inconsistency that a particular toothbrush design could effect plaque at one time but not at another and so the ﬁndings of these analyses may warrant further research. One possible weakness of this review was the grouping of toothbrushes by their modes of action. Whilst this approach allowed more powerful meta-analysis it is possible that toothbrushes whose actions had subtle differences were more or less effective. Similarly, so many factors may inﬂuence the effectiveness of toothbrushes including ﬁlament arrangement, orientation, size, shape and ﬂexibility, brush head size and shape along with presence or absence and characteristics of a timer, that not all of them could be isolated and analysed. Whether the brush has a battery or rechargeable power source may also be important. Publication bias seems likely to be present in the reporting of these trials as manufacturers would like to have scientiﬁc support for the effectiveness of their powered toothbrushes. Studies sponsored by pharmaceutical companies are more likely to favour the sponsor ( Lexchin 2003). However there was no evidence of this when publication bias was examined statistically, and no evidence of a difference in effect estimates when a sensitivity analysis was conducted for trials which did not mention commercial funding. It should be noted that the methods for detecting publication bias are relating effect size to sample size, and in this review the trials tend to be of similar size. Therefore other methods may be required to examine publication bias in short term, low cost studies. Five eligible cross-over trials had to be excluded from the review as the data presented did not include the standard deviation of the paired differences, or alternative statistics which would enable this value to be estimated (Elbourne 2002). Attempts were made to contact all the trialists however they were unable to supply the necessary data. It is important that trialists analyse the data from cross-over trials appropriately and present relevant data in reports of trials. AUTHORS’ CONCLUSIONS 15 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Implications for practice This review has found that compared with manual toothbrushes, powered toothbrushes whose action is rotation oscillational reduce plaque and gingivitis by 11% and 6% respectively in the short term and gingivitis by 17% at greater than 3 months. The clinical signiﬁcance of these reductions is not known. The trials available for the review were too short term to demonstrate whether these effects achieve a reduction in destructive periodontal disease. Individuals who prefer to use a powered toothbrush can be assured that powered toothbrushing is at least as effective as manual brushing and that there is no evidence that it will cause any more injuries to the gums than manual brushing. As none of the trials we found compared the durability, reliability and cost of using manual versus powered brushes, it is presently not possible to make a clear recommendation on toothbrush superiority. Some research designs created an artiﬁcial research environment that may have undermined the generalisability of the ﬁndings. In particular the external validity was questionable in trials with splitmouth designs where participants are asked to clean each side of their mouth with a different brush, in trials where interventions where used in combination and those where toothbrushing was supervised. Hence their exclusion from this meta-analysis. More research with improved rigour is also needed on the relative beneﬁts of powered and manual toothbrushes to prevent or remove extrinsic staining of the teeth and calculus. Finally, empirical data on thresholds for clinically signiﬁcant differences in plaque and gingivitis levels would help to determine whether oral hygiene aids provide important health beneﬁts. ACKNOWLEDGEMENTS Thanks are due to Sylvia Bickley, Trials Search Co-ordinator for the Oral Health Group for carrying out the searches for the review, Liz Asbridge for administration of the review, co-ordination of databases and location of articles for the review. Thanks also go to Anne-Marie Glenny and Emma Tavender for making available their expertise in the ﬁeld of systematic reviews and experience of RevMan and Emma Tavender and Luisa Fernandez for copy editing the ﬁnal draft. For help with the translations of foreign papers our thanks go to Selva Can (German), Regina Mitezki (German), 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 (LeopoldFranzens-Universität), R Nolden (Rheinishe Friedrich-Wilhelms Universität), T Palmer (Clinical Research Associates), M Thompson (Gillette Company), P Warren (Gillette Company). For their help as referees, we express our thanks to Martin Addy, Nik Barstow, Sylvia Bickley, Robin Davies, Marco Esposito, AnneMarie Glenny, Eleanor Grey, Jayne Harrison, Lee Hooper, Ian Needleman and Richard Niederman. Implications for research Trials of longer duration are required to fully evaluate the effects of powered toothbrushes. There are few adequate trials reporting over more than 3 months. Data on the long-term beneﬁts of powered toothbrushes would be valuable in their own right and could be used to trial other outcomes such as the adverse effects and beneﬁts in the prevention of periodontitis and dental caries. Moreover, more trials would lend greater power to systematic reviews of the effectiveness of powered toothbrushes. The review revealed many idiosyncrasies in the design of the trials, in some cases data could not be included in this review. Whilst many of the trials were conducted before the current emphasis on experimental design, even the most recent trials lacked power calculations and had not been analysed on an intention-to-treat basis. Researchers in this ﬁeld would be advised to study guidance on the design and reporting of clinical trials such as that provided in the CONSORT statement (http://www.consort-statement.org/). Speciﬁc guidance exists for trials in the treatment or prevention of periodontal diseases (Imrey 1994) but greater standardisation of both the follow-up intervals and the indices used would beneﬁt both trials and future meta-analyses. Thought should also be given to when the mouth should be examined in relation to when the teeth were last cleaned. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 16 REFERENCES References to studies included in this review Ainamo 1997 {published data only} Ainamo J, Xie Q, Ainamo A, Kallio P. Assessment of the effect of an oscillating/rotating electric toothbrush on oral health. A 12-month longitudinal study. Journal of Clinical Periodontology 1997;24(1): 28–33. Baab 1989 {published data only} Baab DA, Johnson RH. The effect of a new electric toothbrush on supragingival plaque and gingivitis. Journal of Periodontology 1989; 60(6):336–41. Barnes 1993 {published data only} Barnes CM, Weatherford TW 3rd, Menaker L. A comparison of the Braun Oral-B Plaque Remover (D5) electric and a manual toothbrush in affecting gingivitis. Journal of Clinical Dentistry 1993;4(2):48–51. Clerehugh 1998 {published data only} Clerehugh V, Williams P, Shaw WC, Worthington HV, Warren P. A practice-based randomised controlled trial of the efﬁcacy of an electric and a manual toothbrush on gingival health in patients with ﬁxed orthodontic appliances. Journal of Dentistry 1998;26(8): 633–9. Cronin 1998 {published data only} Cronin M, Dembling W, Warren PR, King DW. A 3-month clinical investigation comparing the safety and efﬁcacy of a novel electric toothbrush (Braun Oral-B 3D Plaque Remover) with a manual toothbrush. American Journal of Dentistry 1998;11(Spec No):S17–21. Dentino 2002 {published and unpublished data} Dentino A, Derderian G, Wolf M, Johnson R, Warren P. Evaluation of powered vs manual toothbrushing on plaque, calculus and stain. Journal of Dental Research 1999;78(IADR Abstracts):413 (Abstract No 2463). Dentino A, Wirth C, Williams C, Wolf M, Shaw T, Warren P. Comparison of powered vs manual toothbrushing on gingivitis reduction. Journal of Dental Research 1999;78(IADR Abstracts): 413 (Abstract No 2462). ∗ Dentino AR, Derderian G, Wolf M, Cugini M, Johnson R, Van Swol RL, et al.Six-month comparison of powered versus manual toothbrushing for safety and efﬁcacy in the absence of professional instruction in mechanical plaque control. Journal of Periodontology 2002;73(7):770–8. Emling 1991 {published data only} Emling RC, Raidl A, Greco MR, Shi X, Yankell SL. Clinical evaluation of the Plak Trac toothbrush. Journal of Clinical Dentistry 1991;2(3):57–62. Forgas-B 1998 {published data only} Forgas-Brockmann LB, Carter-Hanson C, Killoy WJ. The effects of an ultrasonic toothbrush on plaque accumulation and gingival inﬂammation. Journal of Clinical Periodontology 1998;25(5):375–9. Galgut 1996 {published data only} Galgut PN. Efﬁcacy of a new electronic toothbrush in removing bacterial dental plaque in young adults. General Dentistry 1996;44 (5):441–5. Garcia-Godoy 2001 {published data only} Garcia-Godoy F, Marcushamer M, Cugini M, Warren PR. The safety and efﬁcacy of a children’s power toothbrush and a manual toothbrush in 6-11 year-olds. American Journal of Dentistry 2001; 14(4):195–9. Glass 1965 {published data only} Glass RL. A clinical study of hand and electric toothbrushing. Journal of Periodontology 1965;36:322–7. Haffajee 2001a {published and unpublished data} Haffajee AD, Thompson M, Torresyap G, Guerrero D, Socransky SS. Efﬁcacy of manual and powered toothbrushes (I). Effect on clinical parameters. Journal of Clinical Periodontology 2001;28(10): 937–46. Heasman 1999 {published data only} ∗ Heasman PA, Stacey F, Heasman L, Sellers P, Macgregor ID, Kelly PJ. A comparative study of the Philips HP 735, Braun/Oral B D7 and the Oral B 35 Advantage toothbrushes. Journal of Clinical Periodontology 1999;26(2):85–90. McCracken GI, Stacy F, Heasman L, Sellers P, Macgregor ID, Kelly PJ, et al.A comparative study of two powered toothbrushes and one manual toothbrush in young adults. Journal of Clinical Dentistry 2001;12(1):7–10. Hickman 2002 {published data only} Hickman J, Millett DT, Sander L, Brown E, Love J. Powered vs manual tooth brushing in ﬁxed appliance patients: a short term randomized clinical trial. Angle Orthodontist 2002;72(2):135–40. Ho 1997 {published data only} Ho HP, Niederman R. Effectiveness of the Sonicare sonic toothbrush on reduction of plaque, gingivitis, probing pocket depth and subgingival bacteria in adolescent orthodontic patients. Journal of Clinical Dentistry 1997;8(1 Spec No):15–9. Johnson 1994 {published data only} Johnson BD, McInnes C. Clinical evaluation of the efﬁcacy and safety of a new sonic toothbrush. Journal of Periodontology 1994;65 (7):692–7. Khocht 1992 {published data only} Khocht A, Spindel L, Person P. A comparative clinical study of the safety and efﬁcacy of three toothbrushes. Journal of Periodontology 1992;63(7):603–10. Lapiere unpublished {unpublished data only} Lapiere A, Donck L, De Vree H, De Boever JA. Effectiveness of three toothbrushes for plaque removal in patients with low compliance. (Europerio 2). Journal of Clinical Periodontology 1997; 24:863. ∗ Lapiere A, Donck L, De Vree H, De Boever JA. Effectiveness of two electric toothbrushes as compared to a manual for plaque control in periodontitis patients with low compliance. Unpublished 2002. Lazarescu 2003 {published data only} Lazarescu D, Boccaneala S, Illiescu A, De Boever JA. Comparative study of an electric and manual toothbrush in patients unfamiliar 17 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. with electric brushes. Journal of Dental Research 2000;79(IADR Abstracts):298 (Abstract No 1234). ∗ Lazarescu D, Boccaneala S, Illiescu A, De Boever JA. Efﬁcacy of plaque removal and learning effect of a powered and a manual toothbrush. Journal of Clinical Periodontology 2003;30(8):726–31. Lobene 1964a {published data only} Lobene RR. Evaluation of altered gingival health from permissive powered toothbrushing. Journal of the American Dental Association 1964;69:585–8. ∗ Lobene RR. The effect of an automatic toothbrush on gingival health. Journal of Periodontology 1964;35:137–9. McAllan 1976 {published data only} ∗ McAllan LH, Murray JJ, Brook AH, Crawford AN. Oral hygiene instruction in children using manual and electric toothbrushes. Beneﬁts after six months. British Dental Journal 1976;140(2):51–6. McAllan LH, Murray JJ, Brook AH, Crawford AN. Oral hygiene instruction in children using manual and electric toothbrushes. Beneﬁts after six months. Journal of Periodontology 1977;48:409. O’Beirne 1996 {published data only} O’Beirne G, Johnson RH, Persson GR, Spektor MD. Efﬁcacy of a sonic toothbrush on inﬂammation and probing depth in adult periodontitis. Journal of Periodontology 1996;67(9):900–8. Pucher 1999 {published data only} Pucher JJ, Lamendola-Sitenga K, Ferguson D, Van Swoll R. The effectiveness of an ionic toothbrush in the removal of dental plaque and reduction on gingivitis in orthodontic patients. Journal of the Western Society of Periodontology/Periodontal Abstracts 1999;47(4): 101–7. Sharma 2000 {published data only} Sharma N, Galustians HJ, Qaqish JG, Rustogi KN, Petrone ME, Volpe AR. Comparative efﬁcacy on supragingival plaque and gingivitis of a manual toothbrush (Colgate Plus) and a batterypowered toothbrush (Colgate Actibrush) over a 30-day period. Compendium of Continuing Education Dental Supplement 2000;21 (31):S9–13. Singh unpublished {unpublished data only} ∗ Singh A, Maddalozzo D, Geivelis M, Koerber A, Cornell W. A clinical comparison of the Butler GUM Pulse plaque remover and manual toothbrushing in adolescent orthodontic patients. Unpublished. Singh A, Maddalozzo D, Geivelis M, Koerber A, Cornell W, Grys E. Efﬁcacy of the Butler Pulse (TM) plaque remover in orthodontic patients. Journal of Dental Research 2000;79(IADR Abstracts):298 (Abstract No 1237). Soparkar 1964 {published data only} Soparkar PM, Quigley GA. Power versus hand brushing: effect on gingivitis. Journal of the American Dental Association 1964;68: 182–7. Soparkar 2000 {published data only} Soparkar PM, Rustogi KN, Petrone ME, Volpe AR. Comparison of gingivitis and plaque efﬁcacy of a battery-powered toothbrush and an ADA-provided manual toothbrush. Compendium of Continuing Education in Dentistry Supplement 2000;(31):S14–8. Sowinski 2000 {published data only} Sowinski JA, Battista GW, Petrone DM, Petrone ME, Rustogi KN, Chaknis P, et al.Comparative efﬁcacy of Colgate Actibrush battery- powered toothbrush and Colgate Plus (manual) toothbrush on established plaque and gingivitis: a 30-day clinical study in New Jersey. Compendium of Continuing Education in Dentistry Supplement 2000;(31):S4–8. Stabholz 1996 {published data only} Stabholz A, Babayof I, Mann J. The clinical effect of a newly designed electric toothbrush on supragingival plaque, gingivitis and gingival bleeding. Journal of Clinical Dentistry 1996;7(1):17–20. Stoltze 1994 {published data only} Stoltze K, Bay L. Comparison of a manual and a new electric toothbrush for controlling plaque and gingivitis. Journal of Clinical Periodontology 1994;21(2):86–90. Terezhalmy 1995a {published data only} Terezhalmy GT, Ifﬂand H, Jelepis C, Waskowski J. Clinical evaluation of the effect of an ultrasonic toothbrush on plaque, gingivitis, and gingival bleeding: a six-month study. Journal of Prosthetic Dentistry 1995;73(1):97–103. Toto 1966 {published data only} Toto PD, Goljan KR, Evans JA, Sawinski VJ. A study on the uninstructed use of an electric toothbrush. Journal of the American Dental Association 1966;72(4):904–5. Tritten 1996 {published data only} Tritten CB, Armitage GC. Comparison of a sonic and a manual toothbrush for efﬁcacy in supragingival plaque removal and reduction of gingivitis. Journal of Clinical Periodontology 1996;23 (7):641–8. van der Weijden 1994 {published data only} van der Weijden GA, Timmerman MF, Reijerse E, Danser MM, Mantel MS, Nijboer A, et al.The long-term effect of an oscillating/ rotating electric toothbrush on gingivitis. An 8-month clinical study. Journal of Clinical Periodontology 1994;21(2):139–45. Van Swol 1996 {published data only} Van Swol RL, Van Scotter DE, Pucher JJ, Dentino AR. Clinical evaluation of an ionic toothbrush in the removal of established plaque and reduction of gingivitis. Quintessence International 1996; 27(6):389–94. Walsh 1989 {published data only} Walsh M, Heckman B, Leggott P, Armitage G, Robertson PB. Comparison of manual and power toothbrushing, with and without adjunctive oral irrigation, for controlling plaque and gingivitis. Journal of Clinical Periodontology 1989;16(7):419–27. Warren 2001 {published data only} Warren PR, Cugini M, Marks P, King DW. Safety, efﬁcacy and acceptability of a new power toothbrush: a 3-month comparative clinical investigation. American Journal of Dentistry 2001;14(1): 3–7. Wilson 1993 {published data only} Wilson S, Levine D, Dequincey G, Killoy WJ. Effects of two toothbrushes on plaque, gingivitis, gingival abrasion, and recession: a 1-year longitudinal study. Compendium Supplement 1993;(16): S569–79. Yankell 1996 {published data only} Yankell SL, Emling RC. A thirty-day evaluation of the Rowenta Dentiphant powered toothbrush in children for safety and efﬁcacy. Journal of Clinical Dentistry 1996;7(4):96–100. 18 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Yankell 1997 {published data only} Yankell SL, Emling RC. A thirty-day safety and efﬁcacy evaluation of the Rowenta, Braun and Sonicare powered toothbrushes and a manual toothbrush. Journal of Clinical Dentistry 1997;8:120–7. Yukna 1993b {published data only} Yukna RA, Shaklee RL. Evaluation of a counter-rotational powered brush in patients in supportive periodontal therapy. Journal of Periodontology 1993;64(9):859–64. Zimmer 2002 {published and unpublished data} Zimmer S, Nezhat V, Bizhang M, Seemann R, Barthel CR. Clinical efﬁcacy of a new sonic/ultrasonic toothbrush. Journal of Clinical Periodontolgy 2002;29(6):496–500. Bader 1995a {published data only} Bader HI. Toothbrushes: manual and electric. Journal of Canadian Dental Association 1995;61(2):83. Bader 1997 {published data only} Bader H, Williams R. Clinical and laboratory evaluation of powered electric toothbrushes: comparative efﬁcacy of two powered brushing instruments in furcations and interproximal areas. Journal of Clinical Dentistry 1997;8(3 Spec No):91–4. Bader 1999 {published data only} Bader HI, Boyd RL. Comparative efﬁcacy of a rotary and sonic powered toothbrush on improving gingival health in treated adult periodontitis patients. American Journal of Dentistry 1999;12(3): 143–7. Barnes 1999 {published data only} Barnes CM, Russell CM, Weatherford TW 3rd. A comparison of efﬁcacy of 2 powered toothbrushes in affecting plaque accumulation, gingivitis, and gingival bleeding. Journal of Periodontology 1999;70(8):840–7. Barnes 2003 {published data only} Barnes CM, Russell CM, Hlava GL, Utecht B, Reinhardt RA. A comparison of a waterpik dual-motor powered toothbrush and a manual toothbrush in affecting interproximal bleeding reduction and dental bioﬁlm accumulation. Journal of Clinical Dentistry 2003;14(3):49–52. Bartizek 2002 {published data only} Bartizek RD, Biesbrock AR. Dental plaque removal efﬁcacy of a battery-powered toothbrush vs. a control Japanese manual toothbrush. American Journal of Dentistry 2002;15 Spec No: 33A–36A. Bastos 1995 {published data only} Bastos EP, Vianna R, Souza I, Heluy D, Primo LG. Clinical evaluation of two toothbrushes under different oral hygiene techniques. Journal of Dental Research 1995;74(IADR Abstracts): 565 (Abstract No 1319). Bhanji 2002 {published data only} Bhanji S, Williams B, Sheller B, Elwood T, Mancl L. Transient bacteremia induced by toothbrushing: a comparison of the Sonicare toothbrush with a conventional toothbrush. Pediatric Dentistry 2002;24(4):295–9. Biesbrock 2002 {published data only} Biesbrock AR, Bayuk LM, Yates DS, Santana MV, Bartizek RD. The clinical effectiveness of a novel power toothbrush and its impact on oral health. Journal of Contemporary Dental Practice 2002;3(2):1–10. Biesbrock 2002a {published data only} Biesbrock AR, Walters PA, Bartizek RD. The relative effectiveness of six powered toothbrushes for dental plaque removal. Journal of Clinical Dentistry 2002;13(5):198–202. Blahut 1993 {published data only} Blahut P. A clinical trial of the INTERPLAK powered toothbrush in a geriatric population. Compendium Supplement 1993;(16): S606–10. Borutta 1997 {published data only} Borutta A. Plaque removal efﬁcacy of a newly developed powered toothbrush in the primary dentition of pre-school children. Journal of Clinical Dentistry 1997;8(6):151–5. 19 References to studies excluded from this review Aass 2000 {published data only} Aass AM, Gjermo P. Comparison of oral hygiene efﬁcacy of one manual and two electric toothbrushes. Acta Odontologica Scandinavica 2000;58(4):166–70. Adriaens 1999 {published data only} Adriaens P. Evaluation of dental plaque removal with New Technology Bristles (NTB) toothbrush. Journal of Dental Research 1999;78:293 (Abstract No 1499). Agerholm 1991 {published data only} Agerholm DM. A clinical trial to evaluate plaque removal with a double-headed toothbrush. British Dental Journal 1991;170(11): 411–3. Ainamo 1991 {published data only} Ainamo J, Hormia M, Kaunisaho K, Sorsa T, Suomalainene K. Effect of manual versus powered toothbrushes. Journal of Dental Research 1991;70:557 (Abstract No 2329). Albers 1988 {published data only} Albers HK, Schusseler BG, Bossmann K. Acceptance and effectivity of electric and hand toothbrushes [Die Akzeptanz und Effektivitat von elektrischen und von Handzahnbursten]. Zahnarztliche Mitteilungen 1988;78(16):1777–80. Anaise 1976 {published data only} Anaise JZ. [Plaque removal by different types of toothbrush]. Israel Journal of Dental Medicine 1976;25(3):19–22. Andreana 1998 {published data only} Andreana S, Cataldo J, Mather ML. Clinical evaluation of the Ionoral toothbrush. Journal of Dental Research 1998;77:211 (Abstract No 847). Arceneaux 1996 {published data only} Arceneaux A, Panacek J, Tellis L, Kiger R, Stephens J, Kettering J. Efﬁcacy of sonic Vs manual toothbrushes in maintaining oral health. Journal of Dental Research 1996;75:86 (Abstract No 551). Ash 1964 {published data only} Ash MM Jr, Rainey BL, Smith WA. Evaluation of manual and motor-driven toothbrushes. Journal of the American Dental Association 1964;69:321–5. Ash 1967 {published data only} Ash M Jr. [An examination of the problems and results in the use of manual and electric toothbrushes]. Revista Espanola de Periodoncia 1967;5(5):269–94. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Boyd 1989a {published data only} Boyd RL, Murray P, Robertson PB. Effect of rotary electric toothbrush versus manual toothbrush on periodontal status during orthodontic treatment. American Journal of Orthodontics & Dentofacial Orthopedics 1989;96(4):342–7. Boyd 1989b {published data only} Boyd RL, Murray P, Robertson PB. Effect on periodontal status of rotary electric toothbrushes vs. manual toothbrushes during periodontal maintenance. I. Clinical results. Journal of Periodontology 1989;60(7):390–5. Boyd 1994 {published data only} Boyd RL, Rose CM. Effect of rotary electric toothbrush versus manual toothbrush on decalciﬁcation during orthodontic treatment. American Journal of Orthodontics & Dentofacial Orthopedics 1994;105(5):450–6. Boyd 1997 {published data only} Boyd RL, McLey L, Zahradnik R. Clinical and laboratory evaluation of powered electric toothbrushes: in vivo determination of average force for use of manual and powered toothbrushes. Journal of Clinical Dentistry 1997;8(3 Spec No):72–5. Braccini 1964 {published data only} Braccini C, Coronelli E. [Considerazioni sul Broxodent alla luce di un esame tecnologico comparativo con altri strumenti similari]. Rivista Italiana di Stomatologia 1964;5:561–72. Bratel 1988 {published data only} Bratel J, Berggren U, Hirsch JM. Electric or manual toothbrush?A comparison of the effects on the oral health of mentally handicapped adults. Clinical Preventive Dentistry 1988;10(3):23–6. Bratel 1991 {published data only} Bratel J, Berggren U. Long-term oral effects of manual or electric toothbrushes used by mentally handicapped adults. Clinical Preventive Dentistry 1991;13(4):5–7. Breuer 1989 {published data only} Breuer MM, Cosgrove R, Hardy D, Nizel A, Schechter SA, Watts MK. A comparison of the plaque-removal efﬁcacies of two electric toothbrushes. Quintessence International 1989;20(7):501–4. Buchmann 1987 {published data only} Buchmann R. Indications and use of electric toothbrushes in individual oral hygiene - a comparison [Indikation und Einsatz von elektrischen Zahnbursten in der individuellen Mundhygiene – Ein Vergleich]. Die Quintessenz 1987;38(3):531–5. Burch 1994 {published data only} Burch JG, Lanese R, Ngan P. A two-month study of the effects of oral irrigation and automatic toothbrush use in an adult orthodontic population with ﬁxed appliances. American Journal of Orthodontics & Dentofacial Orthopedics 1994;106(2):121–6. Chaikin 1965 {published data only} Chaikin BS, Goldman HM, Schulman SM, Ruben MP. Comparative cleansing efﬁciency of power-driven and conventional toothbrushes: I. Effect in uninstructed patients. Periodontics 1965; 149:200–2. Chasens 1968 {published data only} Chasens AI, Marcus RW. An evaluation of the comparative efﬁciency of manual and automatic toothbrushes in maintaining the periodontal patient. Journal of Periodontology 1968;39(3):156–9. Chava 2000 {published data only} Chava V. An evaluation of the efﬁcacy of a curved bristle and conventional tooothbrush. A comparative clinical study. Journal of Periodontology 2000;71(5):785–9. Chilton 1962 {published data only} Chilton NW, Didio A, Rothner JT. Comparison of the clinical effectiveness of an electric and a standard toothbrush in normal individuals. Journal of the American Dental Association 1962;64: 777–82. Christou 1998 {published data only} Christou V, Timmerman MF, Van der Velden U, Van der Weijden FA. Comparison of different approaches of interdental oral hygiene: interdental brushes versus dental ﬂoss. Journal of Periodontology 1998;69(7):759–64. Ciancio 1990 {published data only} Ciancio SG, Mather ML. A clinical comparison of two electric toothbrushes with different mechanical actions. Clinical Preventive Dentistry 1990;12(3):5–7. Ciancio 1998 {published data only} Ciancio S, Shibly O, Mather ML, Al-Mubarak S, Ho A. Clinical comparison of the butler G-U-M(r) Pulse(tm) plaque remover to a manual and electric toothbrush. Journal of Dental Research 1998;77 (IADR Abstracts):211 (Abstract No 845). Ciancio 2002a {published data only} Ciancio S. Electric toothbrushes - for whom are they designed?. Advances in Dental Research 2002;16(1):6–8. Claydon 1995 {published data only} Claydon N, Addy M. The use of planimetry to record and score the modiﬁed Navy index and other area-based plaque indices. A comparative toothbrush study. Journal of Clinical Periodontology 1995;22(9):670–3. Cohen 1964 {published data only} Cohen MM, Winer RA. Comparative effectiveness of manually and power operated toothbrushing on tooth deposits. Periodontics 1964;2:122–4. Conforti 2001 {published data only} Conforti NJ, Chaves ES, Liebman J, Bowman JP, Warren PR, Cugini M. A comparative 3-month clinical investigation of the safety and efﬁcacy of a battery-operated and a rechargeable oscillating-rotating power toothbrush. American Journal of Dentistry 2001;14(2):59–62. Conforti 2003 {published data only} Conforti NJ, Cordero RE, Liebman J, Bowman JP, Putt MS, Kuebler DS, et al.An investigation into the effect of three months’ clinical wear on toothbrush efﬁcacy: results from two independent studies. Journal of Clinical Dentistry 2003;14(2):29–33. Conroy 1965 {published data only} Conroy CW. Comparison of automatic and hand toothbrushes: cleaning effectiveness. Journal of the American Dental Association 1965;70:921–9. Conroy 1966 {published data only} Conroy CW. Comparison of automatic and hand toothbrushes: cleaning effectiveness for children. ASDC Journal of Dentistry for Children 1966;33:219. 20 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Coontz 1983 {published data only} Coontz EJ. The effectiveness of a new oral hygiene device on plaque removal. Quintessence International 1983;14(7):739–42. Coontz 1985 {published data only} Coontz EJ. The effectiveness of a new home plaque-removal instrument on plaque removal. Compendium of Continuing Education in Dentistry 1985;Suppl 6:S117–22. Crawford 1975 {published data only} Crawford AN, McAllan LH, Murray JJ, Brook AH. Oral hygiene instruction and motivation in children using manual and electric toothbrushes. Community Dentistry & Oral Epidemiology 1975;3 (6):257–61. Cronin 1996 {published data only} Cronin M. Comparison of two electric toothbrushes in reducing plaque and gingivitis. Journal of Dental Research 1996;75:86 (Abstract No 550). Cronin 1996a {published data only} Cronin M, Dembling W. An investigation of the efﬁcacy and safety of a new electric interdental plaque remover for the reduction of interproximal plaque and gingivitis. Journal of Clinical Dentistry 1996;7(3 Spec No):74–7. Cronin 2000 {published data only} Cronin MJ, Dembling WZ, Low MA, Jacobs DM, Weber DA. A comparative clinical investigation of a novel toothbrush designed to enhance plaque removal efﬁcacy. Americal Journal of Dentistry 2000;13(Spec No):21A–26A. Cronin 2001 {published data only} Cronin MJ, Dembling W, Conforti NJ, Liebman J, Cugini M, Warren PR. A single-use and 3-month clinical investigation of the comparative efﬁcacy of a battery-operated power toothbrush and a manual toothbrush. American Journal of Dentistry 2001;14 Spec No:19B–24B. Cronin 2002 {published data only} Cronin MJ, Dembling WZ, King DW, Goodman D, Cuigini M, Warren PR. A clinical study of plaque removal with an advanced rechargeable power toothbrush and a battery-operated device. American Journal of Dentistry 2002;15(6):365–8. Cross 1962b {published data only} Cross WG. A comparative study of tooth cleansing using conventional and electrically operated toothbrushes. British Dental Journal 1962;113:19–22. Danser 1998 {published data only} Danser MM, Timmerman MF, IJzerman Y, Bulthuis H, van der Velden U, van der Weijden GA. Evaluation of the incidence of gingival abrasion as a result of toothbrushing. Journal of Clinical Periodontology 1998;25(9):701–6. Danser 1998a {published data only} Danser MM, Timmerman MF, Ijzerman Y, van der Velden U, Warren PR, van der Weijden G. A comparison of electric toothbrushes in their potential to cause gingival abrasion of oral soft tissues. American Journal of Dentistry 1998;11(Spec No):S35–9. Danser 2000 {published data only} Danser MM, Timmerman MF, Ijzerman Y, Piscaer M. Efﬁcacy of novel manual toothbrush compared to electric toothbrush. Journal of Dental Research 2000;79(IADR Abstracts):298 (Abstract No 1236). Danser 2003 {published data only} Danser MM, Timmerman MF, IJzerman Y, Piscaer MI, van der Velden U, van der Weijden G. Plaque removal with a novel manual toothbrush (X-Active) and the Braun Oral-B 3D Plaque Remover. Journal of Clinical Periodontology 2003;30(2):138–44. Derbyshire 1964 {published data only} Derbyshire JC, Mankodi SM. Cleansing effectiveness of conventional and electric toothbrushes: a clinical comparison. Journal of the American Dental Association 1964;69:317–20. Doherty 1998 {published data only} Doherty FM, Jacobs DM, Low ML, Mackay BJ, Weber DA. Antigingivitis and anti-plaque efﬁcacy of two manual toothbrushes. Journal of Dental Research 1998;77:921 (Abstract No 2315). Doherty 1999 {published data only} Doherty F. Plaque removal efﬁcacy of a Novel, advanced toothbrush. Journal of Dental Research 1999;78:216 (Abstract No 885). Doll 1999 {published data only} Doll GM, Typolt A, Sergl HG. The efﬁciency of different toothbrushes in patients with ﬁxed orthodontic appliances. European Journal of Orthodontics 1999;21:581. Donly 2002 {published data only} Donly KJ, Segura A, Walters PA, Bartizek RD, Biesbrock AR. Dental plaque removal with two battery-powered toothbrushes. American Journal of Dentistry 2002;15 Spec No:24A–27A. Dorfer 2001 {published data only} Dorfer CE, von Bethlenfalvy ER, Pioch T, Galustians HJ, Qaqish J, Sharma NC. Clinical evaluation of the efﬁcacy of a battery-powered toothbrush. Results from two independent studies. American Journal of Dentistry 2001;14(5):273–7. Dorfer 2001a {published data only} Dorfer CE, Berbig B, von Bethlenfalvy ER, Staehle HJ, Pioch T. A clinical study to compare the efﬁcacy of 2 electric toothbrushes in plaque removal. Journal of Clinical Periodontology 2001;28(11): 987–94. Driesen 1998 {published data only} Driesen G, Warren P, Hilﬁnger P. Cleaning efﬁcacy of a new electric toothbrush. American Journal of Dentistry 1998;11(Spec No): S7–11. Dunkin 1975 {published data only} Dunkin RT. Abrasiveness of automatic vs. manual toothbrushes. Dental Survey 1975;51(5):36, 39-40, 44. Elliott 1963 {published data only} Elliott JR. A comparison of the effectiveness of a standard and electric toothbrush. Journal of Clinical Periodontology 1963;34: 375–9. Ernst 1998 {published data only} Ernst CP, Nauth C, Willershausen B, Warren PR. Clinical plaque removing efﬁcacy of a new power toothbrush. American Journal of Dentistry 1998;11(Spec No):S13–6. 21 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Fishwick 1998 {published data only} Fishwick MR, Ashley FP, Wilson RF. Can a workplace preventive programme affect periodontal health?. British Dental Journal 1998; 184(6):290–3. Fourel 1974 {published data only} Fourel J, Falabregues R, Hitzig C. [Comparative evaluation of manual and electric brushing]. Actualites Odonto-Stomatologiques 1974;(108):619–46. Fraleigh 1965 {published data only} Fraleigh CM. Tissue changes with manual and electric brushes. Journal of the American Dental Association 1965;70:380–7. Gjebre 1995 {published data only} Gjebre L, Famili P, Close J. Clinical evaluation of gingival health and plaque removal using different toothbrushes. Journal of Dental Research 1995;74:566 (Abstract No 1325). Glavind 1986 {published data only} Glavind L, Zeuner E. The effectiveness of a rotary electric toothbrush on oral cleanliness in adults. Journal of Clinical Periodontology 1986;13(2):135–8. Golden 1964 {published data only} Golden IB, Collins EM. Comparison of plaque removal by two methods of toothbrushing. Journal Of Southern Californian Dentists 1964;33:71–2. Goldman 1975 {published data only} Goldman HM. Effectiveness of an ultrasonic toothbrush in a group of uninstructed subjects. Journal of Periodontology 1975;45:84–7. Grossman 1994 {published data only} Grossman E, Dembling W, Walley DR. Two long-term clinical studies comparing the plaque removal and gingivitis reduction efﬁcacy of the Oral-B Advantage Plaque Remover to ﬁve manual toothbrushes. Journal of Clinical Dentistry 1994;5(2):46–53. Grossman 1995 {published data only} Grossman E, Dembling W, Proskin HM. A comparative clinical investigation of the safety and efﬁcacy of an oscillating/rotating electric toothbrush and a sonic toothbrush. Journal of Clinical Dentistry 1995;6(1):108–12. Grossman 1996 {published data only} Grossman E, Cronin M, Dembling W, Proskin H. A comparative clinical study of extrinsic tooth stain removal with two electric toothbrushes [Braun D7 and D9] and a manual brush. American Journal of Dentistry 1996;9 Spec No:S25–9. Grossman 1997 {published data only} Grossman E, Proskin H. A comparison of the efﬁcacy and safety of an electric and a manual children’s toothbrush. Journal of the American Dental Association 1997;128(4):469–74. Haffajee 2001b {published data only} Haffajee AD, Smith C, Torresyap G, Thompson M, Guerrero D, Socransky SS. Efﬁcacy of manual and powered toothbrushes (II). Effect on microbiological parameters. Journal of Clinical Periodontology 2001;28(10):947–54. Hall 1971 {published data only} Hall AW, Conroy CW. Comparison of automatic and hand toothbrushes: toothbrushing effectiveness for preschool children. Journal of Dentistry for Children 1971;38:309–13. Hansen 1998 {published data only} Hansen PA, Woolsey G, Killoy WJ, Hanson C. Effect of brushing with sonic and counterrotational toothbrushes on the bond strength of full veneer crowns. Journal of Prosthetic Dentistry 1998; 80(4):429–33. Hansen 1999 {published data only} Hansen PA, Killoy W, Masterson K. Effect of brushing with sonic and counterrotational toothbrushes on the bond strength of orthodontic brackets. American Journal of Orthodontics & Dentofacial Orthopedics 1999;115(1):55–60. He 2001 {published data only} He T, Carpinello L, Baker R, Knippenberg S, Das A, Winston L, et al.Safety of three toothbrushes. American Journal of Dentistry 2001; 14(3):123–6. Heasman 1998 {published data only} Heasman P, Wilson Z, Macgregor I, Kelly P. Comparative study of electric and manual toothbrushes in patients with ﬁxed orthodontic appliances. American Journal of Orthodontics & Dentofacial Orthopedics 1998;114(1):45–9. Heasman 2001 {published data only} Heasman P, De Jager M, Stacey F, Heasman L. Testing prototype brush heads for powered toothbrushes - reﬁning the model. Journal of Dental Research 2001;80:548 (Abstract No 0172). Hefti 2000 {published data only} Hefti AF, Stone C. Power toothbrushes, gender, and dentin hypersensitivity. Clinical Oral Investigations 2000;4(2):91–7. Heins 2002 {published data only} Heins P, Bartizek RD, Walters PA, Biesbrock AR. Plaque removal efﬁcacy of a battery-operated power toothbrush compared to two control manual toothbrushes in single use studies. American Journal of Dentistry 2002;15 Spec No:28A–32A. Heintze 1996 {published data only} Heintze SD, Jost-Brinkmann PG, Loundos J. Effectiveness of three different types of electric toothbrushes compared with a manual technique in orthodontic patients. American Journal of Orthodontics & Dentofacial Orthopedics 1996;110(6):630–8. Hellstadius 1993 {published data only} Hellstadius K, Asman B, Gustafsson A. Improved maintenance of plaque control by electrical toothbrushing in periodontitis patients with low compliance. Journal of Clinical Periodontology 1993;20(4): 235–7. Hirsch 1965 {published data only} Hirsch CJ, Held AJ. Comparative experimentation with various types of electric toothbrushes [Experimentation comparative de divers types de brosses a dents electriques]. Revue Mensuelle Suisse d’Odonto-Stomatologie/SSO 1965;75:769–85. Hoover 1962 {published data only} Hoover DR, Robinson HB. Effect of automatic and hand toothbrushing on gingivitis. Journal of the American Dental Association 1962;65:361–7. Horowitz 1992 {published data only} Horowitz LG. Comparing shower-based oral hygiene with traditional and electric toothbrushing. Clinical Preventive Dentistry 1992;14(6):11–6. 22 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Hotta 1992 {published data only} Hotta M, Aono M. A clinical study on the control of dental plaque using an electronic toothbrush with piezo-electric element. Clinical Preventive Dentistry 1992;14(4):16–8. Howorko 1993 {published data only} Howorko N, Gutek M, Naidoo S, Hoover JN. Effectiveness of an electric toothbrush on plaque removal in periodontal patients. American Journal of Dentistry 1993;6(1):49–51. Hunt 2002 {published data only} Hunt S. The relative cleaning effectiveness of manual and powered toothbrushes. Journal of Clinical Dentistry 2002;13(5):211–4. Isaacs 1998 {published data only} Isaacs RL, Beiswanger BB, Rosenﬁeld ST, Crawford JL, Mau MS, Eckert GJ, et al.A crossover clinical investigation of the safety and efﬁcacy of a new oscillating/rotating electric toothbrush and a high frequency electric toothbrush. American Journal of Dentistry 1998; 11(1):7–12. Isaacs 1999 {published data only} Isaacs R, Beiswanger B, Mau M, Rosenfeld S, Boggs S, Proskin G, et al.Clinical comparison of a power toothbrush versus a manual toothbrush. Journal of Dental Research 1999;78(IADR Abstracts): 413 (Abstract No 2464). Jackson 1991 {published data only} Jackson CL. Comparison between electric toothbrushing and manual toothbrushing, with and without oral irrigation, for oral hygiene of orthodontic patients. American Journal of Orthodontics & Dentofacial Orthopedics 1991;99(1):15–20. Jongenelis 1997 {published data only} Jongenelis AP, Wiedemann W. A comparison of plaque removal effectiveness of an electric versus a manual toothbrush in children. ASDC Journal of Dentistry for Children 1997;64(3):176-82, 165. Kambhu 1993 {published data only} Kambhu PP, Levy SM. An evaluation of the effectiveness of four mechanical plaque-removal devices when used by a trained careprovider. Special Care in Dentistry 1993;13(1):9–14. Kanchanakamol 1992 {published data only} Kanchanakamol U, Srisilapanan P. The effectiveness of the newly designed ’Concept 45 degrees’ toothbrush for removal of dental plaque in primary schoolchildren. International Dental Journal 1992;42(2):78–82. Kanchanakamol 1993 {published data only} Kanchanakamol U, Srisilapanan P, Umpriwan R, Kongmalai A. Dental plaque removal in adults using a newly developed, ’Concept 45 degrees’ toothbrush. International Dental Journal 1993;43(2): 116–20. Kaschny 1999 {published data only} Kaschny P. Clinical comparative studies of the efﬁciency of electrical and manual toothbrushes. Oralprophylaxe - Darmstadt 1999;21:80–1. Kilicoglu 1997 {published data only} Kilicoglu H, Yildirim M, Polater H. Comparison of the effectiveness of two types of toothbrushes on the oral hygiene of patients undergoing orthodontic treatment with ﬁxed appliances. American Journal of Orthodontics & Dentofacial Orthopedics 1997; 111(6):591–4. Killoy 1989 {published data only} Killoy WJ, Love JW, Love J, Fedi PF Jr, Tira DE. The effectiveness of a counter-rotary action powered toothbrush and conventional toothbrush on plaque removal and gingival bleeding. A short term study. Journal of Periodontology 1989;60(8):473–7. Killoy 1993 {published data only} Killoy WJ, Love JW, Love JD, Tira DE. Clinical and cost effectiveness of the counter-rotational brush in private practice. Compendium Supplement 1993;(16):S599-605, quiz S612-4. Kugel 2002 {published data only} Kugel G, Boghosian AA. Effects of the sonicare toothbrush for speciﬁc indications. Compendium of Continuing Education in Dentistry 2002;23(7 Suppl 1):11–4. Kugel 2002a {published data only} Kugel G, Boghosian AA. Impact of the sonicare toothbrush on plaque and gingivitis. Compendium of Continuing Education in Dentistry 2002;23(7 Suppl 1):7–10. Kuhner 1993 {published data only} Kuhner M, Raetzke P. Relative effectiveness of various alternating frequencies of a power toothbrush. Journal of Clinical Periodontology 1993;20(2):75–80. Lamendola-Site 1998 {published data only} Lamendola-Sitenga K. Effectiveness of an ionic toothbrush on the removal of plaque in orthodontic patients: A clinical study. Journal of Dental Research 1998;77(IADR Abstracts):123 (Abstract No 140). Lange 1978 {published data only} Lange VDE, Munster RF. Uber die Plaquereduktion durch multiBursten in Verdindung mmit elektrischen Zahnbursten. Deutsche Zahnarztliche Zeitschrift 1978;33:84–7. Leftkowitz 1962 {published data only} Leftkowitz W, Robinson HBG. Effectiveness of automatic and hand brushes in removing dental plaque and debris. Journal of the American Dental Association 1962;65:351–61. Lim 1995 {published data only} Lim LP, Chiu GKC, Davies WIR. Evaluation of a mechanical toothbrush for oral hygiene. Journal of Dental Research 1995;74 (IADR Abstracts):589 (Abstract No 1510). Long 1985 {published data only} Long D, Killoy WJ. Evaluation of the effectiveness of the INTERPLAK home plaque removal instrument on plaque removal and orthodontic patients. Compendium of Continuing Education in Dentistry 1985;Suppl 6:S156–60. Love 1988 {published data only} Love JW, Drisko CL, Killoy WJ, Tira DE, Sackuvich DA. Effectiveness of a rotary action versus a manual toothbrush. Journal of Dental Research 1988;67:125. Love 1993 {published data only} Love JW, Drisko CL, Killoy WJ, Tira DE, Love JD. Clinical assessment of the INTERPLAK toothbrush vs a conventional brush plus ﬂoss. Compendium Supplement 1993;(16):S587-8, S593-8. Lundergan 1988 {published data only} Lundergan WP, Hughes WR, Hall WB. The effectiveness of a powered toothbrush on plaque removal in periodontal patients. Compendium 1988;9(8):658, 660, 662. 23 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Manhold 1965 {published data only} Manhold JH Jr, Franzetti J, Fitzsimmons L. Effect of the electric toothbrush on human gingiva: Histologic and microrepirometer evaluation. Journal of Periodontology 1965;36:135–40. Mantokoudis 2001 {published data only} Mantokoudis D, Joss A, Christensen MM, Meng HX, Suvan JE, Lang NP. Comparison of the clinical effects and gingival abrasion aspects of manual and electric toothbrushes. Journal of Clinical Periodontology 2001;28(1):65–72. Mayer 1978 {published data only} Mayer R, Wieland D, Hemleben C. [Rasterelektronenmikroskopische Untersuchungen der Zahnoberﬂache]. Deutsche Zahnarzliche Zeitschrift 1978;33(9): 599–607. Mayer 1988 {published data only} Mayer R, Zalitis-Cezis IE. Toothbrushing - manual or electromechanical?[Zahneputzen – manuell oder elekrisch–mechanisch?]. ZWR 1988;97(1):50-2, 54. McCracken 2000 {published data only} McCracken GI, Heasman L, Stacey F, Kelly PJ, Heasman PA. Testing the efﬁcacy of plaque removal of a prototype brush head for a powered toothbrush. Journal of Clinical Periodontology 2000;27 (8):542–8. McDaniel 1997 {published data only} McDaniel TF, Miller DL, Jones RM, Davis MS, Russell CM. Effects of toothbrush design and brushing proﬁciency on plaque removal. Compendium of Continuing Education in Dentistry 1997; 18(6):572–7. McInnes 1994 {published data only} McInnes C, Johnson B, Emling RC, Yankell SL. Clinical and computer-assisted evaluations of the stain removal ability of the Sonicare electronic toothbrush. Journal of Clinical Dentistry 1994;5 (1):13–8. McKendrick 1968 {published data only} McKendrick AJ, Barbenel LM, McHugh WD. A two-year comparison of hand and electric toothbrushes. Journal of Periodontal Research 1968;3(3):224–31. McKinney 1990 {published data only} McKinney J, Burns S, Killoy W. Comparison between the counterrotational toothbrush and multi-action toothbrush. Journal of Clinical Dentistry 1990;2(2):39–42. McLey 1995 {published data only} McLey L. Toothbrushes: manual and electric. Journal of the Canadian Dental Association 1995;61(2):83–4. McLey 1997 {published data only} McLey L, Boyd R, Sarker S. Clinical and laboratory evaluation of powered electric toothbrushes: laboratory determination of relative abrasion of three powered toothbrushes. Journal of Clinical Dentistry 1997;8(3 Spec No):76–80. Moran 1995 {published data only} Moran J, Addy M, Warren P, Newcombe R. Stain removal efﬁcacy of two electric toothbrushes. Journal of Dental Research 1995;74 (AADR Abstracts):132 (Abstract No 968). Moran 1995b {published data only} Moran JM, Addy M, Newcombe RG. A comparative study of stain removal with two electric toothbrushes and a manual brush. Journal of Clinical Dentistry 1995;6(4):188–93. Moritis 2002 {published data only} Moritis K, Delaurenti M, Johnson MR, Berg J, Boghosian AA. Comparison of the Sonicare Elite and a manual toothbrush in the evaluation of plaque reduction. American Journal of Dentistry 2002; 15 Spec No:23B–25B. Morris 1997 {published data only} Morris HF, Ochi S, Truhlar R, Olson J. DICRG report: Differences in attachment levels; INTERPLAK (r) vs. manual toothbrushes: 24 month comparison. Journal of Dental Research 1997;76(IADR Abstracts):204 (Abstract No 1527). Moschen 1999 {published data only} Moschen J, Furtlehner H, Kulmer S, Hoerl R, Falk M, Kemmler G. Clinical comparative study of one manual and three electric toothbrushes with different mechanical movement patterns. Deutsche Zahnarztliche Zeitschrift 1999;54:372–9. Mueller 1987 {published data only} Mueller LJ, Darby ML, Allen DS, Tolle SL. Rotary electric toothbrushing. Clinical effects on the presence of gingivitis and supragingival dental plaque. Dental Hygiene 1987;61(12):546–50. Murray 1989 {published data only} Murray PA, Boyd RL, Robertson PB. Effect of periodontal status of rotary electric toothbrushes vs. manual toothbrushes during periodontal maintenance. II. Microbiological results. Journal of Periodontology 1989;60(7):396–401. Nathoo 2000 {published data only} Nathoo S, Rustogi KN, Petrone ME, DeVizio W, Zhang YP, Volpe AR, et al.Comparative efﬁcacy of the Colgate Actibrush batterypowered toothbrush vs Oral-B CrossAction toothbrush on established plaque and gingivitis: a 6-week clinical study. Compendium of Continuing Education in Dentistry 2000;(31):S1924, quiz S35. Niemi 1986 {published data only} Niemi ML, Ainamo J, Etemadzadeh H. Gingival abrasion and plaque removal with manual versus electric toothbrushing. Journal of Clinical Periodontology 1986;13(7):709–13. Niemi 1987 {published data only} Niemi ML. Gingival abrasion and plaque removal after toothbrushing with an electric and a manual toothbrush. Acta Odontologica Scandinavica 1987;45(5):367–70. Niemi 1988 {published data only} Niemi ML, Ainamo J, Etemadzadeh H. [Gingival abrasion and plaque removal with manual vs. electric toothbrushes]. OralProphylaxe 1988;10(1):11–7. Noro 1995 {published data only} Noro T, Miyata T, Tanaka E. Efﬁciency of plaque control with electric toothbrushes. Journal of Dental Research 1995;74:566 (Abstract No 1324). Nowak 2002 {published data only} Nowak AJ, Skotowski MC, Cugini M, Warren PR. A practice based study of a children’s power toothbrush: efﬁcacy and acceptance. 24 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Compendium of Continuing Education in Dentistry 2002;23(3 Suppl 2):25–32. Ohm 1967 {published data only} Ohm HJ, Sonnabend E. Electric toothbrushes impractical tests [Elektrische Zahnbursten im praktischen Test]. Deutsche Zahnarzliche Zeitschrift 1967;22(11):1372–8. Ojima 2003 {published data only} Ojima M, Shizukuishi S, Matsuo T, Kanesaki N, Hanioka T. Comparative clinical study in plaque removal efﬁcacy of a new sonic toothbrush (Float-Brush) with ﬂoating bristle action. Journal of Clinical Dentistry 2003;14(2):42–4. Owen 1972 {published data only} Owen TL. A clinical evaluation of electric and manual toothbrushing by children with primary dentitions. ASDC Journal of Dentistry for Children 1972;39(1):15–21. Palmer 1999 {published data only} Palmer TM, Hall MW, Smith SL, Woolf SH, Ploeger BJ, Christensen RP. Plaque removal capabilities of one manual and ﬁve automated toothbrushes. Journal of Dental Research 1999;78(IADR Abstracts):216 (Abstract No 882). Park 1997 {published data only} Park WE. In vivo removal of plaque from enamel by a sonic toothbrush. Journal Dental Research 1997;76(IADR Abstracts):148 (Abstract No 1079). Plagmann 1978 {published data only} Plagmann HC, Goldkamp B, Lange DE, Morgenroth K. [Uber die mechanische Beeinﬂussung der Alveolarmukosa und der Gingiva durch verschiedene Zahnburstentypen (rasterelektronenmikroskopische Untersuchungen)]. Deutsche Zahnarztliche Zeitschrift 1978;33(1):14–20. Platt 2002 {published data only} Platt K, Moritis K, Johnson MR, Berg J, Dunn JR. Clinical evaluation of plaque removal efﬁcacy and safety of the Sonicare Elite toothbrush. American Journal of Dentistry 2002;15 Spec No: 18B–22B. Powers 1967 {published data only} Powers GK, Tussing GJ, Bradley RE. A comparison of effectiveness in interproximal plaque removal of an electric toothbrush and a conventional hand toothbrush. Periodontics 1967;5(1):37–41. Preber 1991 {published data only} Preber H, Ylipaa V, Bergstrom J, Ryden H. A comparative study of plaque removing efﬁciency using rotary electric and manual toothbrushes. Swedish Dental Journal 1991;15(5):229–34. Priestland 1993 {published data only} Priestland CR, Pethybridge RJ. A clinical trial to compare plaque removing efﬁciency of a prototype toothbrush with alternative toothbrushes. Journal of the Royal Naval Medical Service 1993;79 (1):15–23. Putt 1999 {published data only} Putt M, Davidson K, Milleman J, Kleber C. Comparison of two electric toothbrushes in reducing plaque and gingivitis. Journal of Dental Research 1999;78:413 (Abstract No 2461). Putt 2001 {published data only} Putt MS, Milleman JL, Davidson KR, Cugini M, Warren PR. A 3month clinical comparison of the safety and efﬁcacy of two battery- operated toothbrushes: the Braun Oral-B Battery toothbrush and the Colgate Actibrush. American Journal of Dentistry 2001;14 Spec No:13B–17B. Quigley 1962 {published data only} Quigley GA, Hein JW. Comparative cleansing efﬁciency of manual and power brushing. Journal of the American Dental Association 1962;65:26–9. Quirynen 1994 {published data only} Quirynen M, Vervliet E, Teerlinck J, Darius P, van Steenberghe D. Medium- and long-term effectiveness of a counterrotational electric toothbrush on plaque removal, gingival bleeding, and probing pocket depth. International Journal of Periodontics & Restorative Dentistry 1994;14(4):364–77. Raetzke 2001 {published data only} Raetzke P. The effect of three powered toothbrushes. Journal of Dental Research 2001;79(Spec No):623 (Abstract No 3839). Rapley 1994 {published data only} Rapley JW, Killoy WJ. Subgingival and interproximal plaque removal using a counter-rotational electric toothbrush and a manual toothbrush. Quintessence International 1994;25(1):39–42. Rashid 1998 {published data only} Rashid Z, Kleivmyr M, Aass AM, Gjermo P. The effect upon plaque and gingivitis of two electrical and one manual toothbrush. Journal Dental Research 1998;77(IADR Abstracts):845 (Abstract No 1706). Read 1981 {published data only} Read PW, Fernandes L, Harris P, Henderson M, Goodwill CJ, Smith P. Dental study in patients with rheumatoid arthritis. Rheumatology and Rehabilitation 1981;20(2):108–12. Renton-Harper 1999 {published data only} Renton-Harper P, Addy M, Warren P, Newcombe RG. Comparison of video and written instructions for plaque removal by oscillating/ rotating/reciprocating electric toothbrush. Journal of Clinical Periodontology 1999;26(11):752–6. Renton-Harper 2001 {published data only} Renton-Harper P, Addy M, Newcombe RG. Plaque removal with the uninstructed use of electric toothbrushes: comparison with a manual brush and toothpaste slurry. Journal of Clinical Periodontology 2001;28(4):325–30. Reynolds 1998 {published data only} Reynolds H. Butler “GUM” toothbrushes - A microbiological and clinical study. Journal of Dental Research 1998;77:287 (Abstract No 1452). Robinson 1997 {published data only} Robinson PJ, Maddalozzo D, Breslin S. A six-month clinical comparison of the efﬁcacy of the Sonicare and the Braun Oral-B electric toothbrushes on improving periodontal health in adult periodontitis patients. Journal of Clinical Dentistry 1997;8(1 Spec No):4–9. Ruhlman 2001 {published data only} Ruhlman CD, Bartizek RD, Biesbrock AR. Plaque removal efﬁcacy of a battery-operated toothbrush compared to a manual toothbrush. American Journal of Dentistry 2001;14(4):191–4. 25 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Ruhlman 2002 {published data only} Ruhlman CD, Bartizek RD, Biesbrock AR. Comparative efﬁcacy of two battery-powered toothbrushes on dental plaque removal. Journal of Clinical Dentistry 2002;13(3):95–9. Sarker 1997 {published data only} Sarker S, McLey L, Boyd RL. Clinical and laboratory evaluation of powered electric toothbrushes: laboratory determination of relative interproximal cleaning efﬁciency of four powered toothbrushes. Journal of Clinical Dentistry 1997;8(3 Spec No):81–5. Sato 1995 {published data only} Sato S, Nakagawa T, Kamoi H, Agatsuma H, Yamada S, Kamoi K. Effect of plaque removal by new electric toothbrush. Journal of Dental Research 1995;74:575 (Abstract No 1399). Schemehorn 1995 {published data only} Schemehorn BR, Keil JC. The effect of an oscillating/rotating electric toothbrush and a sonic toothbrush on removal of stain from enamel surfaces. Journal of Clinical Dentistry 1995;6(4):194–7. Schifter 1983 {published data only} Schifter CC, Emling RC, Seibert JS, Yankell SL. A comparison of plaque removal effectiveness of an electric versus a manual toothbrush. Clinical Preventive Dentistry 1983;5(5):15–9. Schmage 1999 {published data only} Schmage P, Platzer U, Nergiz I. Comparison between manual and mechanical methods of interproximal hygiene. Quintessence International 1999;30(8):535–9. Schuler 1996 {published data only} Schuler N, Lang H, Nolden R. Plaque and gingivitis control in children and adults - a comparative study. Journal of Dental Research 1996;75:86 (Abstract No 548). Schwarz 1990 {published data only} Schwarz P, Benz C, Sonnabend E. [Comparative study of the Interplak tooth cleansing instrument]. Deutsche Zahnarztliche Zeitschrift 1990;45(9):557–8. Sgan-Cohen 1995 {published data only} Sgan-Cohen HD, Babayof I, Zadik D, Mann J. One month evaluation of the manually rotating “Bio-Bright” toothbrush for clinical safety and efﬁciency. Journal of Clinical Dentistry 1995;6(1): 120–3. Sharma 1994 {published data only} Sharma NC, Galustians J, McCool JJ, Rustogi KN, Volpe AR. The clinical effects on plaque and gingivitis over three-months’ use of four complex-design manual toothbrushes. Journal of Clinical Dentistry 1994;5(4):114–8. Sharma 1998 {published data only} Sharma NC, Galustian HJ, Qaqish J, Cugini M. A comparison of two electric toothbrushes with respect to plaque removal and subject preference. American Journal of Dentistry 1998;11(Spec No):S29–33. Sharma 1999 {published data only} Sharma N, Galustians H, Quqish J, Cugini M, Warren P. Comparison of two electric toothbrushes in removing extrinsic stain.. Journal of Dental Research 1999;74:414 (Abstract No 2467). Sharma 2000a {published data only} Sharma NC, Galustians HJ, Qaqish J, Cugini M, Warren PR. A comparison of the Braun Oral-B 3D plaque remover and the Sonicare plus electric toothbrush in removing naturally occuring extrinsic staining. American Journal of Dentistry 2000;13(1):17–20. Sharma 2000b {published data only} Sharma NC, Qaqish JG, Galustians HJ, King DW, Low MA, Jacobs DM, et al.A 3-month comparative investigation of the safety and efﬁcacy of a new toothbrush: results from two independent clinical studies. American Journal of Dentistry 2000;13(Spec No):27A–32A. Sharma 2001a {published data only} Sharma NC, Galustians HJ, Qaqish J, Cugini M. Safety and plaque removal efﬁcacy of a battery-operated power toothbrush. American Journal of Dentistry 2001;14 Spec No:9B–12B. Sharma 2002 {published data only} Sharma NC, Galustians HJ, Qaqish J, Cugini M, Warren PR. The effect of two power toothbrushes on calculus and stain formation. American Journal of Dentistry 2002;15(2):71–6. Shaw 1983 {published data only} Shaw L, Harris BM, Maclaurin ET, Foster TD. Oral hygiene in handicapped children: a comparison of effectiveness in the unaided use of manual and electric toothbrushes. Dental Health 1983;22(1): 4–5. Shibly 1997 {published data only} Shibly O, Schifferle RE, Cianco SG, Tarakji M, Mather ML. A clinical comparison of two electric toothbrush designs. Journal of Clinical Periodontology 1997;24(4):260–3. Siebert 2000 {published data only} Siebert K, Glockman I, Glockman E, Sigusch B. Efﬁcacy in plaque removal by three dimensionally working electric toothbrush. Journal of Dental Research 2000;79:298 (Abstract No 1235). Silverstone 1992 {published data only} Silverstone LM, Tilliss TS, Cross-Poline GN, Van der Linden E, Stach DJ, Featherstone MJ. A six-week study comparing the efﬁcacy of a rotary electric toothbrush with a conventional toothbrush. Clinical Preventive Dentistry 1992;14(2):29–34. Sjogren 1998 {published data only} Sjogren K. Initial evidence of interproximal ﬂuoride retention after sonic or manual toothbrushing. Journal of Dental Research. 1998; Vol. 77, issue IADR Abstracts:1018 (Abstract No 3090). Smith 1964 {published data only} Smith WA, Ash MM Jr. A clinical evaluation of an electric toothbrush. Journal of Periodontology 1964;35:127–36. Stadtler 1984 {published data only} Stadtler P. [Effect of electrical toothbrushes and manual toothbrushes on oral hygiene in children]. Zeitschrift fur Stomatologie 1984;81(1):21–4. Stout 1997 {published data only} Stout A, Nazif M, Zullo T, Mckibben D, Trakoﬂaker J. Comparing plaque removal by prophylaxis or toothbrushing in preschool children.. Journal of Dental Research 1997;76:287 (Abstract No 2190). Swenson 1967 {published data only} Swenson HM, Bixler D. Effectiveness of Iontophoresis in the control of plaque and calculus formation in adults. Journal of Periodontology 1967;38:481–3. 26 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Taylor 1995 {published data only} Taylor JY, Wood CL, Garnick JJ, Thompson WO. Removal of interproximal subgingival plaque by hand and automatic toothbrushes. Journal of Periodontology 1995;66(3):191–6. Tenenbaum 1984 {published data only} Tenenbaum H, Kayserlian D. [Comparative evaluation of manual and electric toothbrushes in the elimination of bacterial plaque in a population of dental students]. Journal de Parodontologie 1984;3(3): 295–302. Terezhalmy 1994 {published data only} Terezhalmy GT, Gagliardi VB, Rybicki LA, Kauffman MJ. Clinical evaluation of the efﬁcacy and safety of the UltraSonex ultrasonic toothbrush: a 30-day study. Compendium 1994;15(7):866, 868, 870-2 passim. Thienpont 2001 {published data only} Thienpont V, Dermaut LR, Van Maele G. Comparative study of 2 electric and 2 manual toothbrushes in patients with ﬁxed orthodontic appliances. American Journal of Orthodontics and Dentofacial Orthopaedics 2001;120(4):353–60. Timmerman 1995 {published data only} Timmerman MF, Van Der Weijden GA, Reijerse E, Snoek CM. Toothbrushing force in relation to plaque removal. Journal of Dental Research 1995;74:565 (Abstract No 1318). Timmerman 2001 {published data only} Timmerman M, Piscaer M, Izjerman Y, Van der Velden U. Powered toothbrushing compared to a professional polish. Journal of Dental Research 2001;80:548 (Abstract No 0175). Timmerman 2001a {published data only} Timmerman M, Van der Weijden G, Piscaer M, Ijzerman Y, Van der Velden U. Braun D17 versus Philips HX 2550: an experimental gingivitis study. Journal of Dental Research 2001;80:119 (Abstract No 671). Toh 1995 {published data only} Toh C, Latifah R. A comparison of plaque control between a conventional toothbrush and a unique design toothbrush. Journal of Dental Research 1995;74:589 (Abstract No 1512). Toto 1961 {published data only} Toto PD. Clinical evaluation of an electrically powered toothbrush in home periodontal therapy. Journal of Periodontology 1961;32: 249. Toto 1967 {published data only} Toto PD, Evans CL, Sawinski VJ. Reduction of acidogenic microorganisms by toothbrushing. Journal of Dentistry for Children 1967;34(1):38–40. Trimpeneers 1996 {published data only} Trimpeneers L, Dermaut L, Adriaens UZ. Effect of electric versus manual toothbrushes on plaque removal and periodontal status during orthodontic treatment. (Lecture abstract: 72nd Congress, European Orthodontic Society, Brighton 1996). European Journal of Orthodontics 1996;18:426. Trimpeneers 1997 {published data only} Trimpeneers LM, Wijgaerts IA, Grognard NA, Dermaut LR, Adriaens PA. Effect of electric toothbrushes versus manual toothbrushes on removal of plaque and periodontal status during orthodontic treatment. American Journal of Orthodontics & Dentofacial Orthopedics 1997;111(5):492–7. Trombeli 1995 {published data only} Trombeli L, Scabbia A, Griselli A, Zangari F, Calura G. Clinical evaluation of plaque removal by counterrotational electric toothbrush in orthodontic patients. Quintessence International 1995;26(3):199–202. Tscharre-Z 1989 {published data only} Tscharre-Zachhuber C, Riedl MA, Kulmer S, Kemmler G. [Effectiveness of power toothbrushes]. Zeitschrift fur Stomatologie 1989;86(6):369–75. Twetman 1997 {published data only} Twetman S, McWilliam JS, Hallgren A, Oliveby A. Cariostatic effect of glass ionomer retained orthodontic appliances. An in vivo study. Swedish Dental Journal 1997;21(5):169–75. van der Weij 1993b {published data only} van der Weijden GA, Timmerman MF, Nijboer A, Lie MA, Van der Velden U. A comparative study of electric toothbrushes for the effectiveness of plaque removal in relation to toothbrushing duration. Journal of Clinical Periodontology 1993;20(7):476–81. van der Weijden 1993 {published data only} van der Weijden GA, Danser MM, Nijboer A, Timmerman MF, van der Velden U. The plaque-removing efﬁcacy of an oscillating/ rotating toothbrush. A short-term study. Journal of Clinical Periodontology 1993;20(4):273–8. van der Weijden 1995 {published data only} van der Weijden GA, Timmerman MF, Reijerse E, Mantel MS, van der Velden U. The effectiveness of an electronic toothbrush in the removal of established plaque and treatment of gingivitis. Journal of Clinical Periodontology 1995;22(2):179–82. van der Weijden 1996 {published data only} van der Weijden GA, Timmerman MF, Reijerse E, Snoek CM, van der Velden U. Toothbrushing force in relation to plaque removal. Journal of Clinical Periodontology 1996;23(8):724–9. van der Weijden 1998 {published data only} van der Weijden GA, Timmerman MF, Piscaer M, IJzerman Y, Warren PR, van der Velden U. A comparison of the efﬁcacy of a novel electric toothbrush and a manual toothbrush in the treatment of gingivitis. American Journal of Dentistry 1998;11(Spec No): S23–8. van der Weijden 1999 {published data only} van der Weijden G, Timmerman MF, Piscaer M, IJzerman Y, van der Velden U. Efﬁcacy and gingival abrasion after brushing with three electric toothbrushes. Journal of Dental Research 1999;78 (IADR Abstracts):216 (Abstract No 883). van der Weijden 2001 {published data only} van der Weijden GA, Timmerman MF, Piscaer M, IJzerman Y, van der Velden U. Oscillating/rotating electric toothbrushes compared: plaque removal and gingival abrasion. Journal of Clinical Periodontology 2001;28(6):536–43. van der Weijden 2002 {published data only} van der Weijden GA, Timmerman MF, Piscaer M, Snoek I, Van der Velden U, Galgut PN. Effectiveness of an electrically active brush in the removal of overnight plaque and treatment of gingivitis. Journal of Clinical Periodontology 2002;29(8):699–704. 27 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. van der Weijden1996a {published data only} van der Weijden GA, Timmerman MF, Reijerse E, Snoek CM, Van der Velden U. Comparison of an oscillating/rotating electric toothbrush and a ’sonic’ toothbrush in plaque-removing ability. A professional toothbrushing and supervised brushing study. Journal of Clinical Periodontology 1996;23(4):407–11. van der Weijden1996b {published data only} van der Weijgen FA, Timmerman MF, Snoek IM, Reijerse E, Van der Velden U. Toothbrushing duration and plaque removing efﬁcacy of electric toothbrushes. American Journal of Dentistry 1996;9 Spec No:S31–6. van der Weijden2001a {published data only} van der Weijden G, Timmerman M, Piscaer M, Izerman Y, Van der Velden U. Effect of Sonicare and Braun D17 on experimentallyinduced gingivitis. Journal of Dental Research 2001;80:119 (Abstract No 883). van der Weijden2002a {published data only} van der Weijden GA, Timmerman MF, Piscaer M, IJzerzman Y, van der Velden U. A clinical comparison of three powered toothbrushes. Journal of Clinical Periodontology 2002;29(11):1042–7. van Venrooy 1985 {published data only} van Venrooy JR, Phillips C, Christensen J, Mayhew MJ. Plaque removal with a new powered instrument for orthodontic patients in ﬁxed appliances. Compendium of Continuing Education in Dentistry 1985;Suppl 6:S142–6. Vervliet 1989 {published data only} Vervliet E, Teerlinck J, Quirynen M, van Steenberghe D. The effectiveness of a powered toothbrush (interplak) on plaque removal: a pilot study. Journal of Dental Research 1989;68:614. Walsh 1984 {published data only} Walsh TF, Glenwright HD. Relative effectiveness of a rotary and conventional toothbrush in plaque removal. Community Dentistry and Oral Epidemiology 1984;12(3):160–4. Warren 1998 {published data only} Warren PR, Landmann H, Chater BW. Electric toothbrush use. Attitudes and experience among dental practitioners in Germany. American Journal of Dentistry 1998;11(Spec No):S3–6. Warren 2000 {published data only} Warren PR, Ray TS, Cugini M, Chater BV. A practice-based study of a power toothbrush: assessment of effectiveness and acceptance. Journal of the American Dental Association 2000;131(3):389–94. White 1996 {published data only} White LW. Efﬁcacy of a sonic toothbrush in reducing plaque and gingivitis in adolescent patients. Journal of Clinical Orthodontics 1996;30(2):85–90. Whitmyer 1998 {published data only} Whitmyer CC, Terezhalmy GT, Miller DL, Hujer ME. Clinical evaluation of the efﬁcacy and safety of an ultrasonic toothbrush system in an elderly patient population. Geriatric Nursing 1998;19 (1):29–33. Wiedemann 2001 {published data only} Wiedemann W, Sturm D, de Jager M. Plaque removal efﬁcacy of an electric and a manual toothbrush with additional interdental tufts. Journal of Clinical Dentistry 2001;12(1):21–3. Wilcoxon 1991 {published data only} Wilcoxon DB, Ackerman RJ Jr, Killoy WJ, Love JW, Sakumura JS, Tira DE. The effectiveness of a counterrotational-action power toothbrush on plaque control in orthodontic patients. American Journal of Orthodontics & Dentofacial Orthopedics 1991;99(1):7–14. Willershausen 2001 {published data only} Willershausen B, Watermann L. Longitudinal study to assess the effectivity of electric and manual toothbrushes for children. European Journal of Medical Research 2001;6(1):39–45. Williams 2003 {published data only} Williams K, Haun J, Dockter K, Ferrante A, Bartizek RD, Biesbrock AR. A plaque removal study comparing two advanceddesign oscillating battery-powered toothbrushes. Journal of Clinical Dentistry 2003;14(4):88–92. Williams 2003a {published data only} Williams K, Haun J, Dockter K, Ferrante A, Bartizek RD, Biesbrock AR. Plaque removal efﬁcacy of a prototype power toothbrush compared to a positive control manual toothbrush. American Journal of Dentistry 2003;16(4):223–7. Wilson 1991 {published data only} Wilson S, Levine D, Porush J. A clinical study to compare the antiplaque and antigingivitis effectiveness of 2 electric toothbrushes and a manual toothbrush after 3 months of normal usage. Journal of Periodontology 1991;62:808. Womack 1968 {published data only} Womack WR, Guay AH. Comparative cleansing efﬁciency of an electric and a manual toothbrush in orthodontic patients. Angle Orthodontist 1968;38(3):256–67. Ximenez-Fyvie 2000 {published data only} Ximenez-Fyvie LA, Haffajee AD, Som S, Thompson M, Torresyap G, Socransky SS. The effect of repeated professional supragingival plaque removal on the composition of the supra- and subgingival microbiota. Journal of Clinical Periodontology 2000;27(9):637–47. Yankell 1985 {published data only} Yankell SL, Emling RC, Cohen DW, Vanarsdall R Jr. A four-week evaluation of oral health in orthodontic patients using a new plaque-removal device. Compendium of Continuing Education in Dentistry 1985;Suppl 6:S123–7. Yankell 1992 {published data only} Yankell SL, Raidl AE, Shi X, Emling RC. Thirty-day evaluation of the Stimu-gum gingival stimulator and tooth polisher for clinical safety and efﬁcacy. Journal of Clinical Dentistry 1992;3(4):116–20. Yankell 1994 {published data only} Yankell SL, Emling RC. A study of gingival irritation and plaque removal following a three-minute toothbrushing. Journal of Clinical Dentistry 1994;5(1):1–4. Yankell 1995 {published data only} Yankell S, Emling R. A comparative clinical evaluation of the Wisdom Straight, Plaque Control and Angled toothbrushes compared to Oral-B 35. Journal of Clinical Dentistry 1995;6(4): 202–6. Yankell 1996a {published data only} Yankell S, Emling RC, Perez B. A six-month clinical evaluation of Dentrust toothbrush. Journal of Clinical Dentistry 1996;7(4): 106–9. 28 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Yankell 1997a {published data only} Yankell S, Emling RC, Shi X. Interproximal access efﬁcacy of Sonicare Plus and Braun Oral-B Ultra compared to a manual toothbrush. Journal of Clinical Dentistry 1997;8(1 Spec No):26–9. Yankell 1999 {published data only} Yankell SL, Shi X, Emling RC, Bock RT. Subgingival access and artiﬁcial plaque removal by a sonic cleaning device. Journal of Clinical Dentistry 1999;10(4):139–42. Youngblood 1985 {published data only} Youngblood JJ, Killoy WJ, Love JW, Drisko C. Effectiveness of a new home plaque-removal instrument in removing subgingival and interproximal plaque: a preliminary in vivo report. Compendium of Continuing Education in Dentistry 1985;Suppl 6:S128-32, S141. Yukna 1993a {published data only} Yukna RA, Shaklee RL. Interproximal vs midradicular effects of a counter-rotational powered brush during supportive periodontal therapy. Compendium of Continuing Education in Dentistry 1993; (16):S580-6, quiz S612-4. Zimmer 1999 {published data only} Zimmer S, Didner B, Roulet JF. Clinical study on the plaqueremoving ability of a new triple-headed toothbrush. Journal of Clinical Periodontology 1999;26(5):281–5. Shultz 1995 {published data only} Shultz P. Practical hygiene 1995; Vol. 4:31–5. Additional references Abrams 1984 Abrams K, Caton J, Polson A. Histologic comparisons of interproximal gingival tissues related to the presence or absence of bleeding. Journal of Periodontology 1984;55(11):629–32. Addy 1986 Addy M, Dummer PM, Grifﬁths G, Hicks R, Kingdom A, Shaw WC. Prevalence of plaque, gingivitis and caries in 11-12-year-old children in South Wales. Community Dentistry and Oral Epidemiology 1986;14(2):115–8. Ainamo 1975 Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. International Dental Journal 1975;25(4):229–35. Ash 1964a Ash MM. A review of the problems and results of studies on manual and power toothbrushes. Journal of Periodontology 1964;35: 202–13. Bader 1995 Bader HI. Toothbrushes: manual and electric. Journal of the Canadian Dental Association 1995;61(2):83. Barnett 1980 Barnett ML, Ciancio SG, Mather ML. The modiﬁed papillary bleeding index: comparison with gingival index during the resolution of gingivitis. Journal of Preventative Dentistry 1980;6: 135–8. Begg 1994 Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994;50(4): 1088–101. Brothwell 1998 Brothwell DJ, Jutai DK, Hawkins RJ. An update of mechanical oral hygiene practices: evidence-based recommendations for disease prevention. Journal of the Canadian Dental Association 1998;64(4): 295–306. Chesters 1992 Chesters RK, Huntington E, Burchell CK, Stephen KW. Effects of oral care habits on caries in adolescents. Caries Research 1992;26 (4):299–304. Chilton 1962a Chilton NW, Didio A, Rothner JT. Comparison of the clinical effectiveness of an electric and a standard toothbrush in normal individuals. Journal of the American Dental Association 1962;64: 777–82. Cross 1962 Cross WG, Forrest JO, Wade AB. A comparative study of tooth cleansing using conventional and electrically operated toothbrushes. British Dental Journal 1962;113:19–22. D’Agostino 1992 D’Agostino RB. Discussion: Logical and analytic issues in dental/ oral product comparison research. Journal Periodontal Research 1992;27(4 Pt 2):349–51. 29 References to studies awaiting assessment Boardman 2002 {published data only} Boardman TJ. Statistical issues in assessing powered toothbrushes. Advances in Dental Research 2002;16(1):4–5. Borutta 2002 {published data only} Borutta A, Pala E, Fischer T. Effectiveness of a powered toothbrush compared with a manual toothbrush for orthodontic patients with ﬁxed appliances. Journal of Clinical Dentistry 2002;13(4):131–7. Ciancio 2002 {published data only} Ciancio S. Electric toothbrushes-for whom are they designed?. Advances in Dental Research 2002;16(1):6–8. De Beule 1990 {published data only} De Beule F, Bercy P. [Comparative effectiveness of the Interplak electric rotary toothbrush]. Journal de Parodontologie 1990;9(1): 45–8. Heasman 2002 {published data only} Heasman PA, McCracken GI. Clinical evidence for the efﬁcacy and safety of powered toothbrushes. Advances in Dental Research 2002; 16(1):9–15. Horton 1989 {published data only} Horton J. A study to evaluate a new comercially available rotory type electric toothbrush. Unpublished report Ohio State University. Mayer 1990 {published data only} Mayer R. [Electric toothbrushes--manual toothbrushes, a comparison]. ZWR 1990;99(3):188–92. Sharma 2001 {published data only} Sharma N, Rustogi K, Petrone M, Volpe AR, Sintes J. Comparative efﬁcacy on supragingival plaque and gingivitis of a manual and battery powered toothbrush. (Abstract FDI world dental congress). International Dental Journal 2001;51(5):374. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Deeks 2001 Deeks JJ, Altman DG, Bradburn MJ. Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. In: Egger M, Davey Smith G, Altman DG editor (s). Systematic reviews in health care. 2nd Edition. London: BMJ Books, 2001:285–312. Egger 1997 Egger M, Davey Smith G, Schneider M, Minder C. Bias in metaanalysis detected by a simple, graphical test. BMJ 1997;315(7109): 629–34. Elbourne 2002 Elbourne DR, Altman DG, Higgins JP, Curtin F, Worthington HV, Vail A. Meta-analyses involving cross-over trials: methodological issues. International Journal of Epidemiology 2002;31(1):140–9. Elliot 1963 Elliot JR. A comparison of the effectiveness of a standard and electric toothbrush. Journal of Periodontology 1963;34:375–9. Heasman 1999a Heasman PA, McCracken GI. Powered toothbrushes: a review of clinical trials. Journal of Clinical Periodontology 1999;26(7):407–20. Hoover 1962 Hoover DR, Robinson HB. Effect of automatic and hand toothbrushing on gingivitis. Journal of the American Dental Association 1962;65:361–7. Hoover 1994 Hoover JN, Singer D. Toothbrushes: manual and electric. Journal of the Canadian Dental Association 1994;60(10):880–4. Imrey 1992 Imrey PB. Logical and analytic issues in dental/oral product comparison research. Journal of Periodontal Research 1992;27(4 Pt 2):328–41. Imrey 1994 Imrey PB, Chilton NW, Pihlstrom BL, Proskin HM, Kingman A, Listgarten MA, et al.Recommended revisions to American Dental Association guidelines for acceptance of chemotherapeutic products for gingivitis control. Journal of Periodontal Research 1994;29(4): 299–304. Kaschny 1999 Kaschny P. Clinical comparative studies of the efﬁciency of electrical and manual toothbrushes. Oralprophylaxe - Darmstadt 1999;21:80–1. Lang 1973 Lang NP, Cumming BR, Löe H. Toothbrushing frequency as it relates to plaque development and gingival health. Journal of Periodontology 1973;44(7):396–405. Lang 1998 Lang NP, Attstrom R, Löe H. Commonly used indices to assess oral hygiene and gingival and periodontal health and diseases. Proceedings of the European workshop on mechanical plaque control. Chicago: Quintessence, 1998:50–71. Lexchin 2003 Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ 2003;326(7400):1167–70. Lobene 1986 Lobene RR, Weatherford T, Ross NM, Lamm RA, Menaker L. A modiﬁed gingival index for use in clinical trials. Clinical Preventive Dentistry 1986;8(1):3–6. Loee 1965 Loee H, Theilade E, Jensen SB. Experimental gingivitis in man. Journal of Periodontology 1965;36:177–87. Löe 1963 Löe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontologica Scandinavica 1963;21:533–51. Manhold 1992 Manhold JH, Knutsen M. A retrospective of normal oral healthcare procedures vs. power brush/jet lavage with a corroborative study. Clinical Preventive Dentistry 1992;14(4):10–5. McCracken 2001 McCracken GI, Stacey F, Heasman L, Sellers P, Macgregor ID, Kelly PJ, et al.A comparative study of two powered toothbrushes and one manual toothbrush in young adults. Journal of Clinical Dentistry 2001;12(1):7–10. McLey 1995 McLey LL. Toothbrushes: manual and electric. Journal of the Canadian Dental Association 1995;61(2):83–4. Murtomaa 1992 Murtomaa H, Meurman JH. Mechanical aids in the prevention of dental diseases in the elderly. International Dental Journal 1992;42 (5):365–72. Page 1997 Page RC, Kornman KS. The pathogenesis of human periodontitis: an introduction. Periodontology 2000 1997;14:9–11. Ramfjord 1959 Ramfjord SP. Indices for prevalence and incidence of periodontal disease. Journal of Periodontology 1959:51–9. Richardson 1977 Richardson AS, Boyd MA, Conry RF. A correlation study of diet, oral hygiene and dental caries in 457 Canadian children. Community Dentistry and Oral Epidemiology 1977;5(5):227–30. Russell 1967 Russell, AL. The Periodontal Index. Journal of Periodontology 1967; 38(6):585–91. Rustogi 1992 Rustogi KN, Curtis JP, Volpe AR, Kemp JH, McCool JJ, Korn LR. Reﬁnement of the Modiﬁed Navy Plaque Index to increase plaque scoring efﬁciency in gumline and interproximal tooth areas. Journal of Clinical Dentistry 1992;3(Suppl C):C9–12. Saxer 1997 Saxer UP, Yankell SL. Impact of improved toothbrushes on dental diseases. II. Quintessence International 1997;28(9):573–93. Silness 1964 Silness J, Loee H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontologica Scandinavica 1964;22:121–35. Stålnacke 1995 Stålnacke K, Söderfeldt B, Sjödin B. Compliance in use of electric toothbrushes. Acta Odontologica Scandinavica 1995;53(1):17–9. 30 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Terezhalmy 1995b Terezhalmy GT, Gagliardi VB, Rybicki LA, Kauffman MJ. Clinical evaluation of the efﬁcacy and safety of the Ultrasonex toothbrush: a 30-day study. Compendium 1995;15(7):866, 868, 870-2. Turesky 1970 Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of vitamine C. Journal of Periodontology 1970;41(1):41–3. van der Weijden 1998 van der Weijden GA, Timmerman MF, Danser MM, van der Velden U. The role of electric toothbrushes: advantages and limitations. Proceedings of the European workshop on mechanical plaque control (Status of the art and science of dental plaque control). 1998:138–55. van der Weijden1993a van der Weijden GA, Timmerman MF, Nijboer A, Lie MA, Van der Velden U. A comparative study of electric toothbrushes for the effectiveness of plaque removal in relation to toothbrushing duration. Timerstudy. Journal of Clinical Periodontology 1993;20 (7):476–81. van Swol 1996 van Swol RL, van Scotter DE, Pucher JJ, Dentino AR. Clinical evaluation of an ionic toothbrush in the removal of established plaque and reduction of gingivitis. Quintessence International 1996; 27(6):389–94. Volpe 1965 Volpe AR, Manhold JH, Hazen SP. In vivo calculus assessment. I: A method and its examiner reproducibility. Journal of Periodontology 1965;36:292–8. Walmsley 1997 Walmsley AD. The electric toothbrush: a review. British Dental Journal 1997;182(6):209–18. Warren 1996 Warren PR, Chater B. The role of the electric toothbrush in the control of plaque and gingivitis: a review of 5 years clinical experience with the Braun Oral-B Plaque Remover [D7]. American Journal of Dentistry 1996;9 Spec No:S5–11. Yankell 1980 Yankell SL, Tawil G, Green PA. Overnight plaque formation. Journal of Preventative Dentistry 1980;6:313–5. Yankell 1984 Yankell SL, Green PA, Greco PM, Stoller NH, Miller MF. Test procedures and scoring criteria to evaluate toothbrush effectiveness. Clinical Preventive Dentistry 1984;6(2):3–8. References to other published versions of this review Heanue 2003 Heanue M, Deacon SA, Deery C, Robinson PG, Walmsley AD, Worthington HV, Shaw WC. Manual versus powered toothbrushing for oral health. Cochrane Database of Systematic Reviews 2003, Issue 1. [Art. No.: CD002281. DOI: 10.1002/ 14651858.CD002281] ∗ Indicates the major publication for the study Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 31 CHARACTERISTICS OF STUDIES Characteristics of included studies [ordered by study ID] Ainamo 1997 Methods Participants Interventions Outcomes RCT, parallel, single blind, 12 months, n 112 with 1 drop out. Finland, adults, 20 to 63 years, 64M:47F, bleeding on probing > 30% sites, no medical problems. Braun Oral B Plak Control versus Jordan soft, 2 mins twice daily. Use of timer not stated. Ainamo and Bay Visible Plaque Index and modiﬁed gingival bleeding index. 3, 6 and 12 months. Whole mouth recording PI and GI. No pre-examination instructions reported. Notes Risk of bias Item Allocation concealment? Baab 1989 Methods Participants Interventions Outcomes Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, 1 month, n 41, with 1 drop out. USA, adults, 18 to 59 years, 24M:16F, > 20 teeth with moderate gingivitis, no medical problems. Interplak versus Butler 411, 3 mins twice daily. Use of timer not stated. O’Leary plaque index, Löe and Silness gingival index, Ainamo and Bay gingival bleeding index. Ramfjord teeth for GI, whole mouth for PI. Gingival abrasion reported to be not signiﬁcant. Plaque scores awaiting assessment. Manufacturer funded. No pre-examination instructions reported. Notes Risk of bias Item Allocation concealment? Authors’ judgement Unclear Description B - Unclear Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 32 Barnes 1993 Methods Participants Interventions Outcomes RCT, parallel, single blind, 3 months, n 70 with 1 drop out. USA, adults, 18 to 65 years, > 20 teeth, gingival index > 1.5, plaque index > 2. Braun Oral B Plaque Remover versus Johnson & Johnson Reach, as per normal use. Quigley and Hein (Turesky) Plaque Index, Löe and Silness (Lobene) gingival index at full mouth sites. Soft tissue trauma, no difference between brushes. Whole mouth recording PI and GI. Manufacturer funded. No pre-examination instructions reported. Notes Risk of bias Item Allocation concealment? Clerehugh 1998 Methods Participants RCT, parallel, single blind, 8 weeks, n 84 with 5 drop outs. UK, children and adolescents, 10 to 20 years, orthodontic patients in practice, ﬁxed appliances, gingival bleeding at 30% sites, no medical conditions. Braun Plaque Remover with OD 5 head versus Reach medium compact head, 2 mins twice daily. Timer used. Orthodontic modiﬁcation of Silness and Löe plaque index, Eastman bleeding index at all buccal sites at 4, 8 weeks. No evidence of trauma. One mechanical brush failed. Manufacturer funded. Participants asked to brush in the morning and under supervision prior to assessment. Authors’ judgement Unclear Description B - Unclear Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Cronin 1998 Methods Participants RCT, parallel, single blind, 3 months, n 114, 9 drop outs unclear. USA, adults, > 18 teeth, no medical problems, 18 to 65 years. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 33 Cronin 1998 (Continued) Interventions Braun Oral B 3D Plaque Remover versus standard ADA reference manual, 2 mins twice daily. Timer used. Quigley and Hein (Turesky) plaque index, Löe and Silness gingivitis and bleeding index, at 14, 35 and 90 days, at all sites. Gingival recession recorded, no change seen. No other adverse effects. Whole mouth recording PI and GI. Manufacturer funded. Participants asked to refrain from brushing 12 to 14 hours prior to assessment. Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Dentino 2002 Methods Participants RCT, parallel, single blind, 6 months, n 172 with 15 drop outs. USA, adults, mild to moderate gingivitis with > 20 teeth, no previous powered brush experience. Excluded if pregnant/lactating. Braun Oral B D9 versus ADA accepted standard soft bristle manual, 2 mins twice daily. Use of timer not stated. Quigley and Hein (Turesky) Plaque index and Lobene gingival index at 3 and 6 months. Powered brush removed more calculus. No difference in stain removal reported. PI and GI whole mouth. Manufacturer funded. Participants asked to brush teeth (non-supervised)immediately prior to 6-month plaque assessment. Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Emling 1991 Methods Participants Interventions RCT, parallel, single blind, 30 days, n 60 with 3 drop outs. USA, adults, no medical problems, no current ortho, not pregnant, > 17 teeth, 18 to 60 years. PlaK Trac versus Colgate ADA approved, twice daily. Use of timer not stated. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 34 Emling 1991 (Continued) Outcomes Quigley and Hein (Turesky) Plaque index. Yankell, interproximal plaque index, Löe and Sillness gingival index. Ramfjord teeth for both PI and GI. Pre-brushing measurements used. Notes Risk of bias Item Allocation concealment? Forgas-B 1998 Methods Participants Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, 30 days, n 62 with 6 drop outs. USA, adults, mean age 37 years +/- 10 years, > 16 teeth, plaque index > 2, no medical problems, 21M: 35F. Ultrasonex versus manual Oral B, twice daily. Use of timer not stated. Quigley and Hein (Turesky) Plaque index, Eastman gingival bleeding index at 30 days. Ramfjord teeth for PI and GI. Soft tissue trauma reported, no difference between groups. Manufacturer funded. Participants asked to refrain from brushing for 12 to 14 hours before assessment. Interventions Outcomes Notes Risk of bias Item Allocation concealment? Galgut 1996 Methods Participants Interventions RCT, parallel, single blind, 28 days, n 70 with 7 drop outs. UK, Caucasians, male, 19 to 36 years. Sangi Co Electronic (Active) versus Sangi Co Electronic (non-active), 3 minutes when brushing. No frequency stated. Use of timer not stated. Quigley and Hein (Turesky) Plaque index, Loe and Silness Gingival index at 2, 4 weeks. Whole mouth recording for indices. No adverse events recorded. Manufacturer funded. Assessment after 24 hours of no brushing. Authors’ judgement Unclear Description B - Unclear Outcomes Notes Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 35 Galgut 1996 (Continued) Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Garcia-Godoy 2001 Methods Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate RCT, parallel, single blind, 30 days, n 70 with 4 drop outs. USA, children, 6 to 11 years, able to understand procedure. Braun Oral B D10 per manufacturers instructions versus ADA approved manual brush as normal. Quigley and Hein (Turesky) Plaque index. Whole mouth. No adverse events recorded. Manufacturer funded. Assessment after 12 to 18 hours from last brushing. Glass 1965 Methods Participants Interventions Outcomes RCT, parallel, single blind, 11 months, n 250 with 84 drop outs. USA, dental students, male, 20 to 29 years. GEC powered versus Pycopay brand manual twice daily. Use of timer not stated. Glass debris and gingival indices at 6 weeks, 7 and 11 months at all sites. Stain and calculus reported to be no different between brush types. Whole mouth recording PI and GI. No soft tissue trauma reported. Manufacturer funded. No pre-examination instructions reported. Notes Risk of bias Item Allocation concealment? Authors’ judgement Unclear Description B - Unclear Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 36 Haffajee 2001a Methods Participants Interventions Outcomes RCT, parallel, single blind, 6 months, n 52 with 4 drop outs. USA, systemically healthy participants with adult periodontitis, 20 to 64 years, minimum of 20 teeth. Crest Complete versus Braun Oral-B D15 Plaque Remover. Frequency unclear. Use of timer not stated. Turesky plaque index , Löe and Silness gingival index, bleeding on probing and probing attachment level at baseline, 3 and 6 months. Measurements taken for 6 sites per tooth for up to 28 teeth. Manufacturer funded. No pre-examination instructions reported. Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Heasman 1999 Methods Participants Interventions RCT, parallel, single blind, 6 weeks, n 75 with 1 drop out. UK, adult, > permanent 20 teeth, 18 to 25 years, no medical problems. Braun Oral B D7 versus Philips Jordan HP 735 versus Oral B Advantage B35, > 90 seconds twice daily. Use of timer not stated. Quigley and Hein (Turesky ) plaque index at 24 hours and 6 weeks, Löe and Silness gingival index at 6 weeks, all sites. Whole mouth recording PI and GI. Assessment done within 3 to 4 hours of last brushing. Two powered groups combined for meta-analysis. Outcomes Notes Risk of bias Item Allocation concealment? Hickman 2002 Methods Participants RCT, parallel, blinding unclear, 8 weeks, n 63 with 3 drop outs. UK, orthodontic patients, 10 to 20 years, medically ﬁt. Authors’ judgement Unclear Description B - Unclear Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 37 Hickman 2002 (Continued) Interventions Braun Plaque Remover 3D with Orthodontic head versus Reach compact head manual, 2 mins twice daily. Timer supplied. Silness and Loe plaque index (Orthodontic modiﬁcation)and Loe and Silness gingival index, full mouth at 4 and 8 weeks. Manufacturer funded. Brush as normal post-breakfast. Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Ho 1997 Methods Participants Interventions Outcomes RCT, parallel, single blind, 4 weeks, n 24, drop outs unclear. USA, orthodontic patients, with ﬁxed appliances, 11 to 18 years, gingival index > 2, no medical conditions. Sonicare Ultrasonic versus Oral B P35, 2 mins twice daily. Timer supplied. Silness and Löe gingival and plaque indices on 6 sites per bonded tooth and bleeding on probing all at 4 weeks. Whole mouth recording PI and GI. Manufacturer funded. No pre-examination instructions reported. Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Johnson 1994 Methods Participants Interventions Outcomes RCT, parallel, single blind, 4 weeks, n 51 with 8 drop outs. USA, adult, > 20 teeth, gingival index > 1.5 on Ramjford teeth, no medical conditions, 20 to 54 years. Philips Sonicare versus Oral B 30, 2 mins twice daily. Timer supplied. Quigley and Hein (Turesky) on all sites, Ainamo and Bay gingival index and sulcular bleeding indices on Ramfjord at 1, 2, 4 weeks. Soft tissue trauma “abnormalities” 7 sites in 6 subjects for manual and 10 sites in 7 subjects for powered. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 38 Johnson 1994 (Continued) Notes Manufacturer funded. Post-brushing evaluation. Risk of bias Item Allocation concealment? Khocht 1992 Methods Participants RCT, parallel, single blind, 4 weeks, n 96 with 1 drop out. USA, adults, > 15 teeth with no restorations affecting cervical region plaque score > 1.8 and gingival score > 0.9, no medical conditions. Epident and Interplak versus Oral B 40, twice daily. Use of timer not stated. Quigley and Hein (Turesky) Plaque index and Loe and Silness gingivitis index at all sites at 28 days. Whole mouth recording for PI and GI. No reported soft tissue abrasion. Manufacturer funded. Pre-brushing evaluation. Authors’ judgement Unclear Description B - Unclear Interventions Outcomes Notes Risk of bias Item Allocation concealment? Lapiere unpublished Methods Participants RCT, parallel, single blind, 12 weeks, n 48 with no drop outs stated. Belgium, periodontal patients, 18 to 65 years, 20 natural teeth, no removable dentures, probing pocket depth > 2 mm but < 5 mm, free from subgingival calculus. Philips HP 550 versus P Oral B 35 versus Braun Oral B D5, 2 mins three times a day. Use of timer not stated. Quigley and Hein (Turesky) Plaque index and Loe and Silness gingivitis index, whole mouth at 12 weeks. Funding unclear. No pre-examination instructions reported. Data for two powered brushes combined as same mode of action. Authors’ judgement Unclear Description B - Unclear Interventions Outcomes Notes Risk of bias Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 39 Lapiere unpublished (Continued) Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Lazarescu 2003 Methods Participants Interventions Outcomes RCT, parallel, single blind, 18 weeks, n 80 with 2 drop outs. Romania, adults, > 20 teeth, medically ﬁt and no previous powered brush experience. Philips/Jordan HP 735 versus Oral B 40 manual with normal brushing pattern. Use of timer not stated. Quigley and Hein (Turesky) Plaque index at 6 sites per tooth and gingival bleeding index at proximal smooth surfaces at 18 weeks. Whole mouth recording PI and GI. Manufacturer funded. Assumed pre-brushing evaluation. Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Lobene 1964a Methods Participants Interventions Outcomes Notes RCT, parallel, single blind, n 185, 3 months, drop outs unclear. USA, female college students, aged 17 to 21 years. General electric reciprocating action versus Oral B 40 manual with no instruction. Use of timer not stated. Lobene Gingivitis index at 3 months. Whole mouth recording PI and GI. Manufacturer funded. No pre-examination instructions reported. Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 40 McAllan 1976 Methods Participants Interventions Outcomes RCT, parallel, no blinding, 6 months, n 55 with 15 drop outs. UK, children and adolescents attending paediatric department, 9 to 15 years, 24M: 31F. Touchtronic Teledyne Aqua Tec versus Gibbs short head manual. Use of timer not stated. Silness and Löe plaque whole mouth and Löe and Silness gingival indices at ﬁrst molars and lateral incisor teeth at 1, 2 and 6 months. Manufacturer funded. No pre-examination instructions reported. Notes Risk of bias Item Allocation concealment? Authors’ judgement No Description C - Inadequate O’Beirne 1996 Methods Participants RCT, parallel, single blind, 8 weeks, n 40 drop outs unclear. USA, adults with inﬂammatory periodontal disease, > 20 teeth and received periodontal treatment, 22M: 18F, 18 to 65 years. Sonicare Ultrasonex versus Oral B manual 2 mins twice daily. Timer supplied. Löe and Silness gingival index, Barnett papillary bleeding index at 2, 4 and 8 weeks, at all sites. Whole mouth recording PI and GI. Minor gingival trauma seen in one participant in each group. Part funded by manufacturer. Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Pucher 1999 Methods Participants Interventions RCT, parallel, double blind, 6 weeks, n 60 with 8 drop outs. USA, orthodontic patients, >20 teeth, > 12 years, 23M: 29F after drop outs. Hukuba ionic (active) versus Hukuba ionic (non-active)with usual technique twice daily. Use of timer not stated. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 41 Pucher 1999 (Continued) Outcomes Quigley and Hein (Turesky) plaque index, Loe and Silness gingival index, whole mouth at 6 weeks. No adverse events/ effects recorded. Funding not stated. No brushing for 12 hours and pre-brushing data used. Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Sharma 2000 Methods Participants Interventions Outcomes RCT, parallel, single blind, 30 days, n 62 with 1 drop out. Canada, adults, 18 to 62 years, good general and oral health, 26M: 36F. Colgate Actibrush versus Colgate diamond headed manual for 1 min twice daily. Use of timer not stated. Navy (Rustogi) plaque index, Loe and Silness (Chilton) gingival index, full mouth at 30 days, no adverse effects. Manufacturer funded. No pre-examination brushing for 8 hours. Notes Risk of bias Item Allocation concealment? Singh unpublished Methods Participants Interventions Outcomes Notes Risk of bias Item Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, 60 days, n 73 with 8 drop outs. USA, orthodontic patients, 11 to 19 years, >19 teeth, good health, no prophylaxis within last month. Pulse Plaque Remover versus Oral-B 35, 2 mins. Frequency not stated. Use of timer not stated. Quigley and Hein (Turesky) plaque index, Papillary Bleeding Score (Loesche) for gingivitis. Manufacturer funded. No pre-examination brushing for 12 to 24 hours. Authors’ judgement Description Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 42 Singh unpublished (Continued) Allocation concealment? Soparkar 1964 Methods Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Soparkar 2000 Methods Participants Interventions Outcomes Unclear B - Unclear RCT, parallel, single blind, 11 weeks, n 270 with 32 drop outs. USA, college students non-dental. Unknown action powered versus manual with normal regimen. Use of timer not stated. Quigley and Hein gingival index at 11 weeks. Anterior teeth only. No pre-examination instructions reported. Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, 30 days, n 66 with 3 drop outs. USA, healthy adults, 18 to 70 years, 25 M: 38 F (data on drop outs not presented). Colgate Actibrush versus ADA approved manual brush, 1 min twice daily. Use of timer not stated. Rustogi modiﬁcation of Navy Plaque Index and Mandel-Chilton modiﬁcation of Loe-Silness gingival index, all surfaces. Manufacturer funded. No pre-examination brushing for 8 hours. Notes Risk of bias Item Allocation concealment? Sowinski 2000 Methods Participants Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, 30 days, n 110 with no drop outs. USA, adults, 18 to 70 years, >15 teeth, no Orthodontic appliances, no oral disease, 22M: 88 F. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 43 Sowinski 2000 (Continued) Interventions Outcomes Notes Risk of bias Item Allocation concealment? Stabholz 1996 Methods Participants Interventions Outcomes Colgate Actibrush versus Colgate diamond head manual, 1 min twice daily. Use of timer not stated. Quigley and Hein (Turesky) and Loe and Silness gingival index, full mouth at 30 days. No adverse events. Manufacturer funded. No pre-examination brushing for 24 hours. Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blinded, n 56 with 4 drop outs, 60 days. Israel, general population, no medical conditions. Plaq and White A to Z technology versus Oral B 35 as per normal regimen. Use of timer not stated. Quigley and Hein (Turesky) and Löe and Silness gingival and Eastman BOP indices on Ramfjord teeth at 15 and 30 days. No difference in soft tissue trauma between brush types. Participants asked to refrain from brushing for 12 hours prior to each assessment. Notes Risk of bias Item Allocation concealment? Stoltze 1994 Methods Participants Authors’ judgement Unclear Description B - Unclear RCT, parallel, unclear blinding method used, n 40 with 2 drop outs, 6 weeks. Denmark, young adults 18 to 30 years, with plaque and gingival scores > 1, > 20 teeth, no medical problems. Braun Oral B Plak Control D5 versus Tandex 40 manual, 2 mins twice daily. Use of timer not stated. Silness and Löe plaque index, Löe and Silness gingival index at all sites, 1, 2 and 6 weeks. Whole mouth recording PI and GI. No gingival abrasion reported. No pre-examination instructions reported. Interventions Outcomes Notes Risk of bias Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 44 Stoltze 1994 (Continued) Item Allocation concealment? Terezhalmy 1995a Methods Participants Interventions Outcomes Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, 6 months, n 60 with 14 drop outs. USA, adults, good health and free of oral pathology. Ultra-sonex ultrasonic versus Oral B manual 3 min twice daily. Use of timer not stated. Quigley and Hein (Turesky) plaque index and Löe and Silness gingival index at all sites and Eastman Bleeding on Probing index on contralateral Ramjford teeth. Assessed at 15 and 30 days and 6 months. No soft tissue trauma. Participants asked to refrain from brushing 12 to 14 hours prior to assessment. Notes Risk of bias Item Allocation concealment? Toto 1966 Methods Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Unclear Description B - Unclear RCT, parallel, blinding unclear, 120 days, n 527 with 17 drop outs. USA, boarding school children , 6 to 18 years. Sunbeam cordless versus unspeciﬁed manual. Frequency not stated. Use of timer not stated. PMA index, whole mouth. Funding not clear. No pre-examination instructions. Authors’ judgement Unclear Description B - Unclear Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 45 Tritten 1996 Methods Participants RCT, parallel, single blind, 12 weeks, n 60 with 4 drop outs. USA, adults 18 to 65 years, dental hospital patients, no professional cleaning previous 3 months, minimum 20 teeth, no previous periodontal treatment and unaware of active pregnancy. Sonicare versus Butler 311, 2 minutes twice daily. Timer supplied. Quigley and Hein (Turesky) plaque index all teeth, Löe and Silness gingival index Ramfjord teeth. Gingival abrasion seen in ﬁve manual and one powered brush subjects. Manufacturer funded. Pre-brushing evaluation. Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate van der Weijden 1994 Methods Participants RCT, parallel, single blind, 8 months, n 87 with 10 drop outs. Netherlands, non-dental students, bleeding on probing at least 35% of sites and modiﬁed gingival index of at least 1, no previous experience of electric toothbrush. Healthy. No ortho. No pockets > 5 mm. Braun Plak control versus Butler Gum 311 for 2 mins. Timer supplied. Silness and Löe plaque index, Lobene gingival index at all sites at 1, 2, 5, 8 months. Whole mouth recording PI and GI. Twelve manual brush subjects and ﬁve powered brush subjects with gingival abrasion. Calculus scored no difference in change between groups. Participants asked to brush thoroughly, but not within 1 hour of assessment. Interventions Outcomes Notes Risk of bias Item Allocation concealment? Van Swol 1996 Methods Participants Authors’ judgement Unclear Description B - Unclear RCT, parallel, double blind, 6 months, n 72 with 7 drop outs. USA, adult, > 20 teeth, not using mouthrinses, 9 M: 55 F. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 46 Van Swol 1996 (Continued) Interventions HyG ionic brush (active) versus HyG ionic brush (non-active), usual time twice daily. Use of timer not stated. Quigley and Hein plaque index and Loe and Silness gingival index, whole mouth at 3 and 6 months. Adverse events not reported despite being collected. Manufacturer funded. No pre-examination instructions. Outcomes Notes Risk of bias Item Allocation concealment? Walsh 1989 Methods Participants Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, n 108, 6 months, drop outs unclear. USA, adults from University and dental clinics, 18 to 65 years, > 20 teeth, no dental/medical problems, gingival index > 1 on six+ sites of 18 sites probed on Ramfjord teeth. LPA/Broxo powered versus Oral B 40 manual, twice daily. Use of timer not stated. Silness and Löe plaque index on Ramfjord teeth, BOP on Ramfjord teeth at 3, 6 months. No soft tissue changes reported. Stain reported as no difference between brush types. No pre-examination instructions reported. Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement No Description C - Inadequate Warren 2001 Methods Participants RCT, parallel, single blind, 12 weeks, n 110 with 9 drop outs. USA, adult volunteers, 18 to 65 years, > 18 teeth, plaque index > 1.8, non-smokers, with no medical problems. Braun Oral B D 17 versus ADA standard manual, 2 mins twice daily. Timer supplied. Quigley and Hein (Turesky) plaque index, Löe and Silness gingival index and modiﬁed Löe and Silness Bleeding index, on all sites at 1, 3 months. Whole mouth recording PI and GI. No soft tissue changes reported. 47 Interventions Outcomes Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Warren 2001 (Continued) Notes Manufacturer funded. Participants asked to refrain from brushing 12 to 18 hours prior to assessment. Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate Wilson 1993 Methods Participants RCT, parallel, single blind, 12 months, n 32 with 3 drop outs. USA, adults, 18+ years, minimum 20 teeth, at least 50% tooth surface plaque coverage (O’Leary), bleeding score > 0.75. Barnett-Muhleman Bleeding Index, no medical problems, no orthodontics, no untreated perio or pockets > 6 mm. Interplak, Bausch and Lomb versus Butler 311, 3 minutes. Use of timer not stated. Quigley and Hein (Turesky) plaque index, Barnett Muhleman gingival index on all sites at 1, 2, 6, 9 and 12 months. Whole mouth recording PI and GI. No difference in gingival abrasion found between brush types. Participants asked to brush 1 hour prior to assessment. Interventions Outcomes Notes Risk of bias Item Allocation concealment? Yankell 1996 Methods Participants Interventions Outcomes Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, 4 weeks, n 66 with 1 drop out. USA, children with 4 of 6 Ramfjord teeth present, no medical problems. Rowenta Dentiphant versus Oral B 20, 1 min twice daily. Use of timer not stated. Quigley and Hein (Turesky) plaque and Löe and Silness (Lobene) gingival indices on Ramjford teeth at 2 and 4 weeks. No soft tissue changes reported. Manufacturer funded. Pre-brushing evaluation. Notes Risk of bias Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 48 Yankell 1996 (Continued) Item Allocation concealment? Yankell 1997 Methods Participants Interventions Authors’ judgement Unclear Description B - Unclear RCT, parallel, single blind, 30 days, n 128 with 13 drop outs. USA, adults, 18 to 50 years, > 18 teeth, no current orthodontic bands, no medical problems. Rowenta Plaque Dentacontrol Plus versus Sonicare versus Braun Oral B Ultra versus Oral B P35, 2 min twice daily. Timer speciﬁed for powered. Excluded Rowenta data which were 5 min twice daily. Quigley and Hein (Turesky) plaque and Eastman bleeding indices on Ramfjord teeth and also Löe and Silness (Lobene) gingival index on whole mouth at 4 weeks. No soft tissue changes reported. Rowenta data excluded due to extended brushing period. Participants asked to refrain from brushing 10 to 16 hours before evaluation. Outcomes Notes Risk of bias Item Allocation concealment? Yukna 1993b Methods Participants RCT, parallel, single blind, 6 months, n 42 with 2 drop outs. USA, adults with past periodontal surgical treatment. Excluded if on antibiotics/NSAIDS or orthodontic appliances. Interplak, Bausch and Lomb versus unspeciﬁed manual brush. Use of timer not stated. Quigley and Hein and O’Leary plaque indices, Lobene gingival index and Bleeding on probing. Whole mouth recording PI and GI. 4 of 20 powered brushes had mechanical failure. Manufacturer funded. Authors’ judgement Unclear Description B - Unclear Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Unclear Description B - Unclear Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 49 Zimmer 2002 Methods Participants Interventions Outcomes Notes Risk of bias Item Allocation concealment? Authors’ judgement Yes Description A - Adequate RCT, parallel, single blind, 8 weeks, n 64 with 1 dropout. Germany, adults, 18 to 56 years good general health, no periodontal disease, 32M: 32F. Ultra Sonex Ultima versus Aronal compact manual, 3 mins twice daily. Timer supplied. Quigley and Hein (Turesky) and Papillary bleeding index, full mouth at 4 and 8 weeks. Manufacturer funded. GI = gingival index; PI = plaque index; RCT= randomised controlled trial Characteristics of excluded studies [ordered by study ID] Aass 2000 Adriaens 1999 Agerholm 1991 Ainamo 1991 Albers 1988 Anaise 1976 Andreana 1998 Arceneaux 1996 Ash 1964 Ash 1967 Bader 1995a Bader 1997 Bader 1999 Less than 28 days Manual only Manual only Contacted authors for more information, no reply after 3 months Less than 28 days Less than 28 days No movement of powered head Less than 28 days Not RCT Contacted authors for more information, no reply after 3 months Not RCT Not powered versus manual toothbrushing Not powered versus manual toothbrushing 50 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. (Continued) Barnes 1999 Barnes 2003 Bartizek 2002 Bastos 1995 Bhanji 2002 Biesbrock 2002 Biesbrock 2002a Blahut 1993 Borutta 1997 Boyd 1989a Boyd 1989b Boyd 1994 Boyd 1997 Braccini 1964 Bratel 1988 Bratel 1991 Breuer 1989 Buchmann 1987 Burch 1994 Chaikin 1965 Chasens 1968 Chava 2000 Chilton 1962 Christou 1998 Not powered versus manual toothbrushing Less than 28 days Less than 28 days Not powered versus manual toothbrushing Outcome not under consideration Not RCT Less than 28 days Brush used by another person Less than 28 days Not RCT Not RCT Combined interventions Less than 28 days Not powered versus manual toothbrushing Potential high for compromised self toothbrushing efﬁcacy Potential high for compromised self toothbrushing efﬁcacy Not powered versus manual toothbrushing Less than 28 days Combined intervention Less than 28 days Not RCT Not powered versus manual toothbrushing Split mouth Combined intervention 51 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. (Continued) Ciancio 1990 Ciancio 1998 Ciancio 2002a Claydon 1995 Cohen 1964 Conforti 2001 Conforti 2003 Conroy 1965 Conroy 1966 Coontz 1983 Coontz 1985 Crawford 1975 Cronin 1996 Cronin 1996a Cronin 2000 Cronin 2001 Less than 28 days Contacted authors for more information, no reply after 3 months Not RCT Not powered versus manual toothbrushing Potential high for compromised self toothbrushing efﬁcacy Not powered versus manual toothbrushing Less than 28 days Less than 28 days Less than 28 days Less than 28 days Less than 28 days Not RCT Not powered versus manual toothbrushing Combined intervention Less than 28 days Data on number of participants in each group not presented. The study will be included once these data are determined. Not powered versus manual toothbrushing Less than 28 days Less than 28 days Not powered versus manual toothbrushing Less than 28 days Split-mouth design Less than 28 days Cronin 2002 Cross 1962b Danser 1998 Danser 1998a Danser 2000 Danser 2003 Derbyshire 1964 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 52 (Continued) Doherty 1998 Doherty 1999 Doll 1999 Donly 2002 Dorfer 2001 Dorfer 2001a Driesen 1998 Dunkin 1975 Elliott 1963 Ernst 1998 Fishwick 1998 Fourel 1974 Fraleigh 1965 Gjebre 1995 Glavind 1986 Golden 1964 Goldman 1975 Grossman 1994 Grossman 1995 Grossman 1996 Grossman 1997 Haffajee 2001b Hall 1971 Hansen 1998 Not powered versus manual toothbrushing Less than 28 days Less than 28 days Not powered versus manual toothbrushing Less than 28 days Split-mouth design Laboratory study design Less than 28 days Less than 28 days Not powered versus manual toothbrushing Not RCT Split mouth Split mouth Not powered versus manual toothbrushing Not RCT Not powered versus manual toothbrushing Less than 28 days Less than 28 days Not powered versus manual toothbrushing Less than 28 days Not powered versus manual toothbrushing Outcomes not under consideration Potential high for compromised self toothbrushing efﬁcacy Laboratory study 53 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. (Continued) Hansen 1999 He 2001 Heasman 1998 Heasman 2001 Hefti 2000 Heins 2002 Heintze 1996 Hellstadius 1993 Hirsch 1965 Hoover 1962 Horowitz 1992 Hotta 1992 Howorko 1993 Hunt 2002 Isaacs 1998 Isaacs 1999 Jackson 1991 Jongenelis 1997 Kambhu 1993 Kanchanakamol 1992 Kanchanakamol 1993 Kaschny 1999 Kilicoglu 1997 Killoy 1989 Laboratory study Outcomes not under consideration Not RCT inadequate control Less than 28 days Not powered versus manual toothbrushing Less than 28 days Combined intervention Not powered versus manual toothbrushing Laboratory study Less than 28 days Not RCT Less than 28 days Less than 28 days Not RCT Not powered versus manual toothbrushing Contacted authors for more information, no reply after 3 months Not RCT Less than 28 days Potential high for compromised self toothbrushing efﬁcacy Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not RCT Not powered versus manual toothbrushing Contacted authors for more information, no reply after 3 months 54 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. (Continued) Killoy 1993 Kugel 2002 Kugel 2002a Kuhner 1993 Lamendola-Site 1998 Lange 1978 Leftkowitz 1962 Lim 1995 Long 1985 Love 1988 Love 1993 Lundergan 1988 Manhold 1965 Mantokoudis 2001 Mayer 1978 Mayer 1988 McCracken 2000 McDaniel 1997 McInnes 1994 McKendrick 1968 McKinney 1990 McLey 1995 McLey 1997 Moran 1995 Contacted authors for more information, no reply after 3 months Not an RCT Not an RCT Not powered versus manual toothbrushing No mechanical action of brush head Less than 28 days Less than 28 days Contacted authors for more information, no reply after 3 months Split mouth Contacted authors for more information, no reply after 3 months Combined intervention Less than 28 days Outcomes not under consideration Less than 28 days Less than 28 days Split mouth Not powered versus manual toothbrushing Not powered versus manual toothbrushing Outcomes not under consideration Not RCT Not powered versus manual toothbrushing Not RCT Laboratory study Less than 28 days 55 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. (Continued) Moran 1995b Moritis 2002 Morris 1997 Moschen 1999 Mueller 1987 Murray 1989 Nathoo 2000 Niemi 1986 Niemi 1987 Niemi 1988 Noro 1995 Nowak 2002 Ohm 1967 Ojima 2003 Owen 1972 Palmer 1999 Park 1997 Plagmann 1978 Platt 2002 Powers 1967 Preber 1991 Priestland 1993 Putt 1999 Putt 2001 Less than 28 days Less than 28 days Contacted authors for more information, no reply after 3 months Less than 28 days Contacted authors for more information, after reply still not adequate to be included Outcomes not under consideration Not RCT Less than 28 days Less than 28 days Less than 28 days Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not RCT Less than 28 days Cross-over study, contacted authors for more information, no reply after 3 months Contacted authors for more information, no reply after 3 months Not teeth (e.g. implants, enamel sections on dentures) Not human Less than 28 days Less than 28 days Less than 28 days Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not powered versus manual toothbrushing 56 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. (Continued) Quigley 1962 Quirynen 1994 Raetzke 2001 Rapley 1994 Rashid 1998 Read 1981 Renton-Harper 1999 Renton-Harper 2001 Reynolds 1998 Robinson 1997 Ruhlman 2001 Ruhlman 2002 Sarker 1997 Sato 1995 Schemehorn 1995 Schifter 1983 Schmage 1999 Schuler 1996 Schwarz 1990 Sgan-Cohen 1995 Sharma 1994 Sharma 1998 Sharma 1999 Less than 28 days Split mouth Not powered versus manual toothbrushing Laboratory study Less than 28 days Potential high for compromised self toothbrushing efﬁcacy Not powered versus manual toothbrushing Less than 28 days Not powered versus manual toothbrushing Not powered versus manual toothbrushing Less than 28 days Less than 28 days Laboratory study Less than 28 days Laboratory study Less than 28 days Split mouth Abstract only Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not powered versus manual toothbrushing Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 57 (Continued) Sharma 2000a Sharma 2000b Sharma 2001a Sharma 2002 Shaw 1983 Shibly 1997 Siebert 2000 Silverstone 1992 Sjogren 1998 Smith 1964 Stadtler 1984 Stout 1997 Swenson 1967 Taylor 1995 Tenenbaum 1984 Terezhalmy 1994 Thienpont 2001 Timmerman 1995 Timmerman 2001 Timmerman 2001a Toh 1995 Toto 1961 Toto 1967 Trimpeneers 1996 Not powered versus manual toothbrushing Not powered versus manual toothbrushing Split-mouth design Outcomes not under consideration Potential high for compromised self toothbrushing efﬁcacy Not powered versus manual toothbrushing Not powered versus manual toothbrushing Contacted authors for more information, no reply after 3 months Less than 28 days Cross-over study, contacted authors for more information, no reply after 3 months Less than 28 days Outcome not under consideration Contacted authors for more information, no reply after 3 months Less than 28 days Less than 28 days Not RCT Cross-over study, contacted authors for more information, no reply after 3 months Less than 28 days Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not RCT Outcomes not under consideration Duplicate abstract of included study 58 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. (Continued) Trimpeneers 1997 Trombeli 1995 Tscharre-Z 1989 Twetman 1997 van der Weij 1993b van der Weijden 1993 van der Weijden 1995 van der Weijden 1996 van der Weijden 1998 van der Weijden 1999 van der Weijden 2001 van der Weijden 2002 van der Weijden1996a van der Weijden1996b van der Weijden2001a van der Weijden2002a van Venrooy 1985 Vervliet 1989 Walsh 1984 Warren 1998 Warren 2000 White 1996 Whitmyer 1998 Wiedemann 2001 Cross-over study, contacted authors for more information, no reply after 3 months Less than 28 days Combined interventions Not powered versus manual toothbrushing Not powered versus manual toothbrushing Less than 28 days Not powered versus manual toothbrushing Less than 28 days Split-mouth study Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not powered versus manual toothbrushing Not powered versus manual toothbrushing Split-mouth study Split-mouth study Less than 28 days Split mouth Less than 28 days Not RCT Not powered versus manual toothbrushing Not RCT Potential high for compromised self toothbrushing efﬁcacy Split mouth 59 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. (Continued) Wilcoxon 1991 Willershausen 2001 Williams 2003 Williams 2003a Wilson 1991 Womack 1968 Ximenez-Fyvie 2000 Yankell 1985 Yankell 1992 Yankell 1994 Yankell 1995 Yankell 1996a Yankell 1997a Yankell 1999 Youngblood 1985 Yukna 1993a Zimmer 1999 Cross-over study, contacted authors for more information, no reply after 3 months Not RCT Less than 28 days Less than 28 days Contacted authors for more information, no reply after 3 months Not RCT Not powered versus manual toothbrushing Not RCT Not powered versus manual toothbrushing Less than 28 days Not powered versus manual toothbrushing Not powered versus manual toothbrushing Laboratory study Laboratory study Laboratory study Combined intervention Less than 28 days RCT = randomised controlled trial Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 60 DATA AND ANALYSES Comparison 1. Side to side powered toothbrushes versus manual toothbrushes Outcome or subgroup title 1 Plaque scores at 1 to 3 month at all sites 1.1 Quigley Hein (Turesky) 1.2 Silness and Löe 2 Gingival scores at 1 to 3 months at all sites 2.1 Löe and Silness 2.2 Lobene gingival index 2.3 BOP 3 Plaque scores at > 3 months 3.1 Quigley Hein (Turesky) 3.2 Silness and Löe 4 Gingival scores at > 3 months 4.1 Löe and Silness 4.2 Lobene Gingival Index No. of studies 6 4 2 8 4 3 1 2 1 1 2 1 1 No. of participants 402 324 78 627 174 410 43 220 166 54 220 54 166 Statistical method Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Effect size -0.42 [-0.91, 0.07] -0.14 [-0.36, 0.08] -1.72 [-4.93, 1.49] -0.44 [-0.91, 0.02] -0.60 [-1.34, 0.14] -0.39 [-1.24, 0.46] -0.10 [-0.70, 0.50] 0.03 [-0.23, 0.29] 0.04 [-0.26, 0.34] Not estimable 0.12 [-0.14, 0.39] Not estimable 0.16 [-0.14, 0.47] Comparison 2. Counter oscillation Outcome or subgroup title 1 Plaque scores at 1 to 3 month at all sites 1.1 Quigley Hein (Turesky) 2 Gingivitis scores at 1 to 3 months at all sites 2.1 Gingival Index Löe 2.2 Lobene gingival index 2.3 BOP 3 Plaque scores at > 3 months 3.1 Quigley Hein (Turesky) 4 Gingival scores at > 3 months 4.1 Lobene gingival index 4.2 BOP No. of studies 4 4 4 2 1 1 2 2 2 1 1 No. of participants 184 184 172 103 40 29 69 69 69 40 29 Statistical method Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Effect size -0.07 [-0.36, 0.22] -0.07 [-0.36, 0.22] -0.04 [-0.52, 0.45] -0.11 [-1.22, 0.99] -0.03 [-0.65, 0.59] 0.06 [-0.68, 0.79] -0.63 [-1.11, -0.14] -0.63 [-1.11, -0.14] -0.19 [-0.66, 0.29] -0.18 [-0.80, 0.44] -0.19 [-0.93, 0.54] Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 61 Comparison 3. Rotation oscillation Outcome or subgroup title 1 Plaque scores at 1 to 3 month at all sites 1.1 Quigley Hein (Turesky) 1.2 Silness and Löe 1.3 Visible plaque index Ainamo Bay 1.4 Ortho modiﬁcation of Silness and Löe 1.5 Navy plaque index mod Rustogi 2 Gingival scores at 1 to 3 months at all sites 2.1 Löe and Silness mod Lobene 2.2 Löe and Silness 2.3 Loe and Silness mod Chilton 2.4 Lobene gingival index 2.5 BOP Ainamo Bay 3 Plaque scores at > 3 months 3.1 Quigley Hein (Turesky) 3.2 Silness and Löe 3.3 Visible plaque index Ainamo Bay 4 Gingival scores at > 3 months 4.1 Lobene gingival index 4.2 BOP Ainamo Bay No. of studies 15 10 2 1 1 1 16 1 9 2 3 1 3 1 1 1 4 2 2 No. of participants 1181 834 115 111 60 61 1256 69 663 124 290 110 266 78 77 111 423 234 189 Statistical method Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Effect size -0.43 [-0.72, -0.14] -0.35 [-0.73, 0.03] -1.17 [-2.74, 0.40] -0.26 [-0.63, 0.12] Not estimable -0.71 [-1.22, -0.19] -0.62 [-0.90, -0.34] -0.67 [-1.16, -0.18] -0.74 [-1.16, -0.32] -1.23 [-1.90, -0.56] -0.11 [-0.46, 0.24] -0.21 [-0.58, 0.17] -1.29 [-2.67, 0.08] -2.95 [-3.60, -2.30] -0.73 [-1.19, -0.26] -0.28 [-0.66, 0.09] -0.51 [-0.76, -0.25] -0.36 [-0.63, -0.09] -0.66 [-1.08, -0.24] Comparison 4. Circular Outcome or subgroup title 1 Plaque scores at 1 to 3 month at all sites 1.1 Quigley Hein (Turesky) 1.2 Silness and Löe 2 Gingival scores at 1 to 3 months at all sites 2.1 GI Löe Silness 2.2 Lobene 3 Plaque scores at > 3 months 3.1 Silness and Löe No. of studies 3 2 1 3 2 1 1 1 No. of participants 168 128 40 168 103 65 40 40 Statistical method Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Effect size -0.06 [-0.36, 0.25] -0.02 [-0.37, 0.33] -0.17 [-0.80, 0.45] -0.39 [-0.95, 0.18] -0.35 [-1.34, 0.64] -0.50 [-0.99, -0.00] 0.04 [-0.58, 0.66] 0.04 [-0.58, 0.66] 62 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 4 Gingival scores at > 3 months 4.1 Löe and Silness 1 1 40 40 Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) -0.30 [-0.92, 0.33] -0.30 [-0.92, 0.33] Comparison 5. Ultrasonic Outcome or subgroup title 1 Plaque scores at 1 to 3 month at all sites 1.1 Quigley Hein (Turesky) 2 Gingival scores at 1 to 3 months at all sites 2.1 Löe and Silness 2.2 Papillary bleeding index 3 Plaque scores at > 3 months at all sites 3.1 Quigley Hein 4 Gingival scores at > 3 months 4.1 Löe and Silness No. of studies 3 3 3 2 1 1 1 1 1 No. of participants 171 171 171 108 63 46 46 46 46 Statistical method Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Effect size -1.13 [-2.42, 0.15] -1.13 [-2.42, 0.15] -0.64 [-1.04, -0.24] -0.55 [-1.17, 0.07] -0.82 [-1.34, -0.31] 0.20 [-0.38, 0.78] 0.20 [-0.38, 0.78] Not estimable Not estimable Comparison 6. Unknown or other action Outcome or subgroup title 1 Plaque scores at 1 to 3 months at all sites 1.1 Quigley Hein (Turesky) 2 Gingival scores at 1 to 3 months at all sites 2.1 Löe and Sillness 2.2 Quigley and Hein 3 Gingival scores > 3 months at all sites 3.1 PMA No. of studies 1 1 3 2 1 1 1 No. of participants 57 57 360 122 238 510 510 Statistical method Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI) Effect size -0.32 [-0.84, 0.20] -0.32 [-0.84, 0.20] -0.38 [-0.59, -0.17] -0.24 [-0.60, 0.12] -0.46 [-0.73, -0.19] -0.16 [-0.34, 0.02] -0.16 [-0.34, 0.02] Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 63 Comparison 7. Ionic brushes Outcome or subgroup title 1 Plaque scores at 1 to 3 months at all sites 1.1 Quigley Hein (Turesky) 2 Gingival scores at 1 to 3 months at all sites 2.1 Loe Silness 3 Plaque scores at > 3 months at all sites 3.1 Quigley Hein (Turesky) 4 Gingival scores at > 3 months at all sites 4.1 Loe and Silness No. of studies 3 3 2 2 1 1 1 1 No. of participants 179 179 116 116 64 64 64 64 Statistical method Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI) Std. Mean Difference (IV, Fixed, 95% CI) Effect size -0.28 [-0.58, 0.01] -0.28 [-0.58, 0.01] -0.14 [-0.51, 0.22] -0.14 [-0.51, 0.22] -1.01 [-1.53, -0.49] -1.01 [-1.53, -0.49] -0.78 [-1.29, -0.27] -0.78 [-1.29, -0.27] WHAT’S NEW Last assessed as up-to-date: 16 February 2005. 20 August 2008 Amended Converted to new review format. HISTORY Protocol ﬁrst published: Issue 2, 2000 Review ﬁrst published: Issue 1, 2003 Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 64 17 February 2005 New citation required and conclusions have changed Substantive amendment. More studies have been included for brushes that work with a rotation oscillation action. The update conﬁrms that these brushes removed more plaque and reduced gingivitis more effectively than manual brushes in the short term. Brushes of this design reduced gingivitis scores over 3 months. A reﬁnement of the data analysis for brushes that work with a rotation oscillation action excluded one study from the current review for plaque over 3 months. Excluding this study does not substantially change our estimate of the treatment effect. However, because there are fewer studies in the analysis the 95% conﬁdence intervals are wider and the ﬁndings are no longer statistically signiﬁcant for this analysis. Trials of ionic brushes that impart a charge to the tooth surface have been included for the ﬁrst time. The analyses show no beneﬁt from these brushes on plaque or gingivitis in studies lasting 1 to 3 months but effects in studies over 3 months. This inconsistency cannot be explained but only one study was included in the longterm analyses. This review has been repeated, 2 years after it was ﬁrst completed. The original review included 29 trials involving 2547 subjects. 42 trials are now included, involving 3855 participants. 17 February 2005 New search has been performed CONTRIBUTIONS OF AUTHORS Bill Shaw and Helen Worthington wrote the protocol. Anne-Marie Glenny, Bill Shaw, Mike Heanue, Peter Robinson and Damien Walmsley 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 and Damien Walmsley 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 and Mike Heanue checked and entered data. Peter Robinson and Mike Heanue wrote the review. Proof reading and numerical consistency checked by Anne-Marie Glenny and Chris Deery. Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 65 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. 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. External sources • No sources of support supplied INDEX TERMS Medical Subject Headings (MeSH) Devices, Home Care [adverse effects; economics]; Dental Plaque [complications; ∗ prevention & control]; Gingival Diseases [prevention & control]; Gingivitis [∗ prevention & control]; Oral Health; Periodontal Diseases [prevention & control]; Randomized Controlled Trials as Topic; Toothbrushing [∗ instrumentation; methods] ∗ Dental MeSH check words Humans Manual versus powered toothbrushing for oral health (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 66

Manual versus powered toothbrushing for oral health

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