J Clin Periodontol 2002; 29(Suppl.

3): 39–54 Copyright # Blackwell Munksgaard 2002

Printed in Denmark. All rights reserved

ISSN 1600-2865

Review article

A systematic review of powered A. Sicilia, I. Arregui, M. Gallego,

B. Cabezas, and S. Cuesta
Section of Periodontology, University Clinic of
Dental Surgery, Faculty of Medicine, University of

vs. manual toothbrushes in Oviedo, Oviedo, Spain

periodontal cause-related
therapy
Sicilia A, Arregui I, Gallego M, Cabezas B, Cuesta S: A systematic review of powered vs.
manual toothbrushes in periodontal cause-related therapy. J Clin Periodontol 2002;
29(Suppl. 3): 39–54. # Blackwell Munksgaard, 2002.

Abstract
Background: Power-driven toothbrushes (PDT) have been designed to improve
the efficacy of oral hygiene. It is not clear how they compare in efficacy with
manual toothbrushes in cause-related periodontal therapy.
Objectives: To evaluate the effectiveness of the use of a PDT as compared with
a manual toothbrush (MT), in terms of gingival bleeding or inflammation
resolution, in cause-related periodontal therapy.
Material and methods: An electronic (MEDLINE and Cochrane Oral Health
Group Specialised Trials Register) and a manual search were made to detect
studies which permitted the evaluation of the efficacy of PDT in the reduction
of gingival bleeding or inflammation, and their effect on other secondary
variables. Only randomized studies in adults, published in English up to June
2001, which compared a PDT with an MT, and evaluated the evolution of
gingival bleeding or inflammation were included. The selection of articles,
extraction of data and assessment of validity were made independently by
several reviewers.
Results: Twenty-one studies were finally selected. The heterogeneity of the data
prevented a quantitative analysis. A higher efficacy in the reduction of gingival
bleeding or inflammation in the PDT patients was detected in 10 studies. This
effect appears to be related to the capacity to reduce plaque, and is more
evident in counter-rotational and oscillating-rotating brushes. No solid
evidence was found for a higher efficacy of sonic brushes. In short-term studies
with prophylaxis after initial examination, independently of the type of PDT
tested, no significant differences were found.
Conclusion: The use of PDT, especially counter-rotational and oscillating-rotating
brushes, can be beneficial in reducing the levels of gingival bleeding or inflammation. Key words: electric toothbrushes; periodontal
There is a need for methodological homogeneity in future studies in this field to diseases/therapy; powered toothbrushes;
enable quantitative analysis of their results. systematic review

As periodontal investigation began to
discover the aetiological effect of dental
plaque and the therapeutic role of oral
hygiene became clear (Axelsson &
Lindhe 1981, Lang et al. 1973, Löe
et al. 1965), procedures, techniques
and electrically powered devices were
consequently developed to help patients
in this task.
Efficient oral hygiene is relatively
tedious, requires time and is, for some
people, difficult to achieve (Khocht et al.
1992). This has led from the beginning of
the 1960s to the development and com-
mercialization of electric toothbrushes
(Ainamo et al. 1997, Baab & Johnson
1989). The studies made in these decades
have produced contradictory results.
40 Sicilia et al.
Ash (1964), in a classic review, con-
cluded that professional dental care
and oral hygiene instructions were
more important than any type of
brush. This absence of efficacy was
apparently endorsed by some authors
(Greene 1966), while others found the
opposite. Of the six studies reviewed in
1968 comparing the effects of a manual
toothbrush with that of an electric one in
the treatment of gingivitis, four found
no differences, while two, of only
3 months’ duration, found a significant
reduction of the gingivitis in users of the
electric brush (McKendrick et al. 1968).
During the 1980s and 1990s, new prod-
ucts with sophisticated action mechan-
isms appeared. These were designed to
improve the efficacy of their predecessors
(Ainamo et al. 1997, Heasman et al.
1999, Killoy et al. 1989, Stoltze & Bay
1994, Walsh et al. 1989), although recent
reviews have not found any solid evi-
dence for such (Hancock 1996, van der
Weijden et al. 1998). However, the con-
tinuous evolution in this field has made
a systematic review of the literature
necessary, with the aim of evaluating the
available evidence which could justify
the use of electric toothbrushes in the
treatment of patients with gingivitis or
periodontitis.
The objective of this review is to eval-
uate the effectiveness of the use of a
power-driven toothbrush as compared
with a manual toothbrush in terms of
gingival bleeding or inflammation reso-
lution in the treatment of gingivitis and
chronic periodontitis patients.
Material and methods
A protocol detailing the method was
designed prior to the commencing of
this systematic review. This protocol
was peer-reviewed by a group made
up of members of the Cochrane Oral
Health Group and the European
Federation of Periodontology.
Study selection
Randomized controlled trials which
compare the efficacy of dental hygiene
with an electric or conventional
manual toothbrush in the treatment
of gingivitis were selected. Patients
had to be older than 15 years at the
beginning of the study, present gingi-
vitis or periodontitis, not be handi-
capped, and be without implants,
extensive prosthetic restoration or
orthodontic treatment.
The treatment of interest (test) has
been the use of an electric toothbrush,
and the standard treatment of reference
(control) the use of a manual tooth-
brush. The main outcome variable has
been the reduction of the gingivitis, as
measured by the reduction of gingival
bleeding or inflammation.
In cases where a study registered two
gingival indexes, one based on gingival
bleeding and the other on the inflamma-
tion, we have preferably used the former.
The reduction of plaque and the appear-
ance of gingival abrasions and complica-
tions have been evaluated as secondary
variables. Among these, we were equally
interested in the possible effect of the
study factor
the use of the electric
toothbrush
on gingival recession, on
which we have found specific data in
only two studies (Johnson & McInnes
1994, McKendrick et al. 1968).
Searching
A search was made in the MEDLINE
and Cochrane Oral Health Group
Specialised Trials Register databases,
using June 2001 as the final date. The
selection strategy consisted of a free
text search of the sequence:
‘electr’ OR ‘power’ OR ‘rota’ OR
‘ultraso’ OR ‘oscillat’ AND ‘toothbrush’
OR (the MeSH terms) ‘dental-devices-
home-care’ OR ‘dental-plaque-therapy’.
The articles were searched for and
retrieved by means of the program End-
Note5 (ISI Researchsoft 2001, Berkeley,
CAhttp://www.endnote.com)whichwas
also used for the elaboration of the final
list and the exchange of information
among reviewers. The search was limited
to articles in English. Classical reviews,
letters and clinical articles were excluded.
A complementary manual search
which included a complete revision
up to June 2001 was made of the
following journals: Journal of Clinical
Periodontology, Journal of Periodontal
Research and Journal of Periodontology
and also the bibliographies of reviews
of interest, relevant texts or previous
workshops. The possible existence of
material ‘in press’ (or accepted for
publication) was requested from the
editors of the above cited journals.
Once the described search was made,
we obtained a total of 343 articles. In
the first phase two groups of reviewers
(B.C., M.G., S.C. and I.A.) evaluated
the possible inclusion in our systematic
review of the articles cited, studying
the information found in titles and
abstracts. The discrepancies were
resolved by discussion. Articles of poten-
tial interest, but which did not meet all
of the selection conditions, were searched
for in order to evaluate the complete
text. All clinical studies in which the
efficacy of an electric toothbrush was
compared with a manual one were
specially included in this preselection.
In the second phase, two reviewers
(I.A. and A.S.) independently evaluated
the entire text of the 62 preselected
articles.
Validity assessment
The evaluation of the quality of the
methodology of the studies selected,
and the final data extraction, was
done independently by two examiners
(I.A. and A.S.), and the concordance
was evaluated by means of the Kappa
test. Four aspects were analysed:
* the adequacy of the method of
randomization;
* the allocation concealment;
* the existence of blinding of the
examiners for the variable ‘type of
treatment’;
* the existence and treatment of lost
cases.
Qualitative data synthesis
After a preliminary evaluation of the
selected articles, we found considerable
heterogeneity in the study methodo-
logy, characteristics of the included
patients, type of treatments provided,
outcome variables registered and
results. Thus, it was not possible to
make a quantitative synthesis of the
data and the consequent meta-analysis
(Jadad 2000, first edition 1998). We
have therefore attempted, in its place,
to tabulate the data from a descriptive
point of view, according to ‘models’
with common characteristics.
Results
Study characteristics
Of the 62 articles finally obtained,
21 were considered valid and 41 were
excluded for the following reasons:
* No evidence of randomization in the
assignment to treatment was detected
(nine articles) (Ash et al. 1964, Boyd
et al. 1989a, Chasens & Marcus 1968,
Glavind & Zeuner 1986, Hellstadius

et al. 1993, Hoover & Robinson 1962,
Powers et al. 1967, Rainey & Ash 1964,
Silverstone et al. 1992).
* No information on bleeding or
gingival inflammation of the patients
evaluated was published (18 articles)
(Ciancio & Mather 1990, Cross et al.
1962, Danser et al. 1998, Grossman
et al. 1996, Haffajee et al. 2001a,
Howorko et al. 1993, Kambhu &
Levy 1993, Murray et al. 1989, Niemi
1987, Niemi et al. 1986, Preber et al.
1991, Renton-Harper et al. 2001,
Sanders & Robinson 1962, Schifter
et al. 1983, van der Weijden et al. 1993a,
1993b, 1996, Zimmer et al. 1999).
* Incomplete information of gingival
bleeding or inflammation was repor-
ted (three articles). None of these
published patient-based data or
provided information which per-
mitted the calculation of such data
(Aass & Gjermo 2000, Haffajee et al.
2001b, Mantokoudis et al. 2001).
* The sample population was made up
of patients younger than 15 years of
age (three articles) (Lefkowitz et al.
1962, Ritsert & Binns 1967, Toto et al.
1966).
* The patients were undergoing
orthodontic treatment (five articles)
(Boyd et al. 1989b, Burch et al. 1994,
Trombelli et al. 1995, Wilcoxon et al.
1991, Womack & Guay 1968).
* Devices and procedures which were
not applicable to our study were
evaluated (two articles): in one case
the test group used a manual brush
together with an electric interdental
stimulator (Glickman et al. 1965),
and in the other, patients brushed
with an unpowered electric tooth-
brush (van der Weijden et al. 1995).
* Finally, one article (Yukna & Shaklee
1993b) was excluded because the data
appeared to duplicate another study
(Yukna & Shaklee 1993a, Khan et al.
2001).
Of 21 articles finally included in
this review, 15 presented short or
medium term data (Table 1) and six
were long-term studies with 6 or more
months of follow-up (Table 2).
Methodological quality of included studies
All the studies included (Tables 1
and 2) are defined by their authors
Powered vs. manual toothbrushes in cause-related therapy
as randomized. However, a precise
description of the procedure employed,
which allows us to evaluate whether the
randomization was adequate, was only
found in seven cases (Baab & Johnson
1989, Chilton et al. 1962, Killoy et al.
1993, Lobene 1964, O’Beirne et al. 1996,
Quirynen et al. 1994, Tritten &
Armitage 1996) (Kappa score for
interreviewer agreement: 0.70, 95% CI:
0.41–0.99, P ¼ 0.0003, indicating good
agreement).
The allocation concealment of treat-
ments is clearly shown in six studies
(Baab & Johnson 1989, Chilton et al.
1962, Killoy et al. 1993, O’Beirne
et al. 1996, Quirynen et al. 1994,
Tritten & Armitage 1996) (Kappa
score for interreviewer agreement:
0.77, 95% CI: 0.46–1.0, P ¼ 0.00001,
indicating good agreement).
The blinding procedure of the exami-
ners is not clear in only two articles
(Stoltze & Bay 1994, Terezhalmy et al.
1994) (Kappa score for interreviewer
agreement: 0.99, 95% CI: 0.99–0.99,
P ¼ 0.000005, indicating very good
agreement). Given the characteristics
of this type of studies it is not possible
to achieve a masking for the patient.
In 11 studies, cases were lost during
the follow-up period. This represented
between one and 28 per cent of the
included patients. In these studies,
no allowance was made for the losses to
follow-up in the data analysis (Ainamo
et al. 1997, Forgas-Brockmann et al.
1998, Johnson & McInnes 1994,
Khocht et al. 1992, Killoy et al. 1993,
McKendrick et al. 1968, O’Beirne et al.
1996, Stoltze & Bay 1994, Terezhalmy
et al. 1994, van der Weijden et al. 1994,
Yukna & Shaklee 1993a).
The majority of the studies have
employed a model of two parallel
groups of independent patients, one
being the experimental group with
an electric toothbrush and the other
with a manual brush (Tables 1 and 2).
Only two studies employed three
groups of patients, two experimental
groups with different electric tooth-
brushes and a control group (Heasman
et al. 1999, Khocht et al. 1992). On
the other hand, on three occasions
a different design of the parallel
groups has been used, employing
the same patients as tests and controls
(Chilton et al. 1962, Quirynen et al.
1994, van der Weijden et al. 1998b),
and in another two a crossover design
was used (Love et al. 1993, Quirynen
et al. 1994).
41
In four articles the mean patient-
based data of gingival bleeding or
inflammation in each group are unclear
(Ainamo et al. 1997, Chilton et al.
1962, Forgas-Brockmann et al. 1998,
Quirynen et al. 1994), and in nine
the baseline–end-of-study reduction
differences of the outcome variable
between groups are not analysed
(Heasman et al. 1999, Johnson &
McInnes 1994, Khocht et al. 1992,
Killoy et al. 1993, Killoy et al. 1989,
Love et al. 1993, Tritten & Armitage
1996, van der Weijden et al. 1994,
1998b).
In seven out of 21 cases a measure
of dispersion was not added to the
presentation of data, or the standard
error was erroneously employed in its
place (Baab & Johnson 1989, Killoy
et al. 1993, Love et al. 1993, McKendrick
et al. 1968, O’Beirne et al. 1996,
Stoltze & Bay 1994, van der Weijden
et al. 1998b).
The definition of the study popula-
tion is not as precise as it should be.
For example, some authors do not
publish the age range of the patients
studied (Tables 1 and 2) (Chilton et al.
1962, Killoy et al. 1993, Killoy et al.
1989, Lobene 1964, Love et al. 1993,
Terezhalmy et al. 1994, van der Weijden
et al. 1994).
Finally, statistical errors were
found in six out of 20 cases. These
included:
1 accepting a P < 0.05 as significant in
a study with multiple exploratory ana-
lyses (van der Weijden et al. 1998b),
2 errors in calculation or interpret-
ation (Killoy et al. 1993, Stoltze &
Bay 1994),
3 confusing use of complex techniques
of analysis? (Terezhalmy et al. 1994)
and
4 accepting baseline significant dif-
ferences between the test and the
control groups for the response
variable? (Johnson & McInnes 1994,
Killoy et al. 1993).
Reduction of gingival bleeding or
inflammation and dental plaque
In general, clear information on the
severity of the periodontal disease
present at the beginning of the study
is not available. It is shown in the text
in 13 cases, or it can be deduced from
the data, that the patients have gingi-
vitis, but information on the possible
 42

Table 1. Characteristics of the selected ‘short- and medium-term’ studies

Study Methods Participants Interventions Outcome variables Cause-related therapy provided
1
Baab & Johnson (1989) RCT 40 adult subjects Control: Manual brush Butler 411 Bleeding/gingivitis: Oral hygiene treatment
2 treatment groups (20 test, 20 control group) (modified Bass) GBI Compliance-controlled
Parallel groups Age 18–59 years Test: Counter-rotational electric Plaque:
Sicilia et al.

1 month’s duration Gingivitis or brush (Interplak1) OPCR

Chilton et al. (1962)
Split mouth (upper and
Forgas-Brockmann et al.
(1998)
Heasman et al. (1999)
15 months’ duration
Johnson & McInnes
(1994)
Khocht et al. (1992)
Killoy et al. (1989)
Lobene (1964)
moderate periodontitis
RCT 30 dental students
2 treatment groups Gingivitis (no information
of periodontitis)
lower)
2 months’ duration
RCT 56 adult patients
2 treatment groups (30 test, 26 control group)
Parallel groups Age 20–60 years
1 month’s duration Gingivitis (no information
of periodontitis)
RCT 75 subjects
3 treatment groups (25 test I, 25 test II, 25
Parallel groups control group)
Age 18–25 years
Mild gingivitis (no
information of
periodontitis)
RCT 43 subjects
2 treatment groups (24 test, 19 control group)
Parallel groups Age 20–54 years
1 month’s duration Gingivitis (no
information of
periodontitis)
RCT 95 subjects
3 treatment groups (32 test I, 32 test II, 31
Parallel groups control group)
1 month’s duration Age 18–65 years
Gingivitis or moderate
periodontitis
RCT 24 patients
2 treatment groups (12 test, 12 control group)
Parallel groups Adults
1 month’s duration Gingivitis (no information
of periodontitis)
RCT 185 women of college age
2 treatment groups (92 test, 93 control group)
Parallel groups Adults
3 months’ duration Gingivitis (no information
of periodontitis)
Control: Standard brush Bleeding/gingivitis: Normal hygiene
Test: Electric brush (Broxodent1) PMA Over-the-counter model
Plaque:
CI
Control: Manual brush Oral B1 Bleeding/gingivitis: Normal hygiene
(modified Bass) EBI Over-the-counter model
Test: Ultrasonic electric brush Plaque:
(Ultra-sonex1) PI
Control: Manual brush Oral B 35 Bleeding/gingivitis: Baseline profilaxis
adv1 (modified Bass) GI Oral hygiene treatment
Test I: Oscillating-rotating electric Plaque: Compliance-controlled
brush (Phillips Jordan 2-Action1) PI
Test II: Oscillating-rotating
electric brush (Braun Oral B
D71)
Control: Manual brush Oral B Bleeding/gingivitis: Oral hygiene treatment
301 (modified Bass) GBI Compliance-controlled
Test: Sonic electric brush Plaque:
(Sonicare1) PI
Control: Manual brush Oral B 40 Bleeding/gingivitis: Oral hygiene treatment
adv1 (modified Bass) GI Compliance-controlled
Test I: Oscillating-rotating electric Plaque:
brush (Epident1) PI
Test II: Counter-rotational electric
brush (Interplak1)
Control: Conventional toothbrush Bleeding/gingivitis: Oral hygiene treatment
(conventional brushing) BMBI Compliance-controlled
Test: Counter-rotational electric Plaque:
brush (Interplak1) PI
Control: Manual brush Oral B 40 Bleeding/gingivitis: Normal hygiene
adv1 (no instruction) PMA Over-the-counter model
Test: Reciprocating electric brush
(General Electric1)
Love et al. (1993)* RCT 30 SPT patients Control: Manual brush Butler 3111 Bleeding/gingivitis: Baseline profilaxis-scaling
2 treatment groups (16 test, 14 control group) (modified Bass plus dental BMBI Oral hygiene treatment
Parallel groups mean age 40 years floss) Plaque:
2 months’ duration Gingivitis (no information Test: Counter-rotational electric OPCR
of periodontitis-SPT) brush (Interplak1)
O’Beirne et al. (1996) RCT 40 SPT patients Control: Manual brush Oral B1 Bleeding/gingivitis: Oral hygiene treatment
2 treatment groups (20 test, 20 control group) (modified Bass) MPBI
Parallel groups Age 31–56 years Test: Sonic electric brush
2 months’ duration Gingivitis or periodontitis (Sonicare1)
Quirynen et al. (1994){ RCT 6 dental students Control: Manual brush Oral B 301 Bleeding/gingivitis: Baseline and 1 month
2 treatment groups (6 test, 6 control group) (modified Bass) SBI profilaxis
Split mouth (quadrants 1–3 Age 20–24 years Test: Counter-rotational electric Plaque: Oral hygiene treatment
and 2–4) Gingivitis and moderate brush (Interplak1) Q-HPI
3 months’ duration periodontitis
Stoltze & Bay (1994) RCT 38 medical students Control: Manual brush Tandex1 Bleeding/gingivitis: Normal hygiene
2 treatment groups (20 test, 18 control group) (no instruction) BSI Over-the-counter model
Parallel groups Age 18–30 years Test: Oscillating-rotating electric Plaque:
1.5 months’ duration Gingivitis (no information brush (Braun D5 Plak Control1) VPLI
of periodontitis)
Terezhalmy et al. (1995) RCT 46 subjects Control: Manual brush Oral B1 Bleeding/gingivitis: Oral hygiene treatment
2 treatment groups (23 test, 23 control group) (no instruction) EBI
Parallel groups Adults Test: Ultrasonic electric brush Plaque:
1 month’s duration Gingivitis (no information (Ultra-sonex1) PI
of periodontitis)
Tritten & Armitage RCT 56 subjects Control: Manual brush Butler 3311 Bleeding/gingivitis: Oral hygiene treatment
(1996) 2 treatment groups (29 test, 27 control group) (modified Bass) BOP
Parallel groups Age 22–59 years Test: Sonic electric brush Plaque:
1 month’s duration Gingivitis and moderate (Sonicare1) PI
periodontitis
Van der Weijden et al. RCT 35 University students Control: Manual brush Butler 3111 Bleeding/gingivitis: Oral hygiene treatment
(1998) 2 treatment groups (35 test, 35 control group) (modified Bass) BMPI
Split mouth (right and left Adults Test: Oscillating-rotating electric Plaque:
side) Experimental gingivitis brush (Braun Oral-B 3D1) PI
1 month’s duration
GBI, Ainamo & Bay modified gingival bleeding index; OPCR, O’Leary plaque control record; PMA, PMA index of gingivitis; CI, Chilton cleanliness index; EBI, Eastman bleeding index;
PI, Turesky plaque index; GI, Löe and Silness gingival index; BMBI, Barnett-Mühlemann bleeding index; MPBI, Modified papillary bleeding index; SBI, Mühlemann and Son sulcus
bleeding index; Q-HPI, Quigley and Hein plaque index; BSI, % of sites with bleeding to stroking or showing ‘spontaneous’ bleeding, codes 2 or 3 GI; VPLI, % of sites with ‘visible plaque’,
codes 2 or 3 PlI; BOP, bleeding on probing; BMPI, bleeding on marginal probing index; SPT patients, supportive periodontal therapy patients.
*A 4-month crossover study with two parallel groups. Inadequate wash-out period at 2 months. Only information from the first 2 months is employed.
{The authors report two studies. The first, which is included here, is a 3-month study. The second is a long-term crossover study, with data not applicable to this review.
Powered vs. manual toothbrushes in cause-related therapy
43
 44

Table 2. Characteristics of the selected ‘long-term’ studies

Study Methods Participants Interventions Outcome variables Cause-related therapy provided
Sicilia et al.

1
Ainamo et al. (1997) RCT 111 office workers Control: Manual brush Jordan soft Bleeding/gingivitis: Baseline profilaxis
2 treatment groups (55 test, 56 control group) (modified Bass) GBI Oral hygiene treatment
Parallel groups Age 20–63 years Test: Oscillating-rotating electric Plaque:
12 months’ duration Gingivitis (no information brush (Braun Oral B Plak VPI
of periodontitis) Control1)
Killoy et al. (1993) RCT 29 SPT patients Control: Conventional toothbrush Bleeding/gingivitis: SPT when needed
2 treatment groups (16 test, 13 control group) (conventional brushing) BMBI Surgery when needed
Parallel groups Adults Test: Counter-rotational electric Plaque: Oral hygiene treatment
18 months’ duration Moderate periodontitis brush (Interplak1) PI
(Initial phase of perio.
treatment before baseline)
McKendrick et al. (1968)* RCT 40 University students Control: Manual brush Gibb’s1 Bleeding/gingivitis: Oral hygiene treatment
2 treatment groups (19 test, 21 control group) (‘‘roll’’ technique) RPI
Parallel groups Age 18–33 years Test: Arcuate movement electric Plaque:
24 months’ duration Mild gingivitis brush (Ronson1) ODI
Van der Weijden et al. RCT 77 University students Control: Manual brush Butler Bleeding/gingivitis: Baseline and one month
(1994) 2 treatment groups (non-dental) GUM 3111 (modified Bass) BA profilaxis
Parallel groups (42 test, 35 control group) Test: Oscillating-rotating electric Plaque: Oral hygiene treatment
8 months’ duration Mean age 22 years brush (Braun Plak Control1) PI Compliance-controlled
Gingivitis or moderate
periodontitis
Walsh et al. (1989){ RCT 54 University students, Control: Manual brush Oral-B 401 Bleeding/gingivitis: Profilaxis-scaling at three
2 treatment groups staff, and general (modified Bass) BOP months’
Parallel groups population Test: Oscillating electric brush Plaque: Oral hygiene treatment
6 months’ duration (27 test, 27 control group) (Broxo1) VPLI
Age 28–65 years
Gingivitis (no information
of periodontitis)
Yukna & Shaklee (1993) RCT 40 SPT patients Control: Conventional toothbrush Bleeding/gingivitis: SPT when needed
2 treatment groups (20 test, 20 control group) (conventional brushing plus BOP Oral hygiene treatment
Parallel groups Age 34–81 years interproximal aids) Plaque:
6 months’ duration Gingivitis (no information Test: Counter-rotational electric PI
of periodontitis-SPT) brush (Interplak1)
GBI, Ainamo & Bay modified gingival bleeding index; VPI, Ainamo & Bay visible plaque index; BMBI, Barnett-Mühlemann bleeding index; PI, Turesky plaque index; RPI, Russell Periodontal
Index; ODI, Greene and Vermilion oral debris index; BA, bleeding assessment; VPLI, % of sites with ‘visible plaque’, codes 2 or 3 P1I; BOP, bleeding on probing; SPT patients, supportive
periodontal therapy patients.
*The authors report two studies, one in oral-hygiene-instructed patients (included here), and the other in oral-hygiene-uninstructed patients.
{Four groups in the study, two with oral irrigation and two without. Patients belonging to groups with oral irrigation were excluded from this study’s data abstraction.
 Powered vs. manual toothbrushes in cause-related therapy 45

existence of periodontitis is not given.
In six cases, information is given in a
general way of the existence of gingi-
vitis and/or moderate periodontitis in
the patients evaluated. Clear informa-
tion is only given in two articles of the
existence of gingivitis alone, one of
which is a study in patients with
experimental gingivitis (Tables 1 and 2).
We made a descriptive estimation
of the baseline levels of gingival
bleeding or inflammation and plaque,
calculating the mean value at baseline
for all the patients of each study, and
the percentage which this represents
in relation to the maximum value of
the scale (or index) with which it has
been measured (Table 3). The initial
relative values of inflammation thus
obtained ranged between 8 and 80%,
and those of the plaque between
23 and 81% (Table 3).
The use of so many different
indices, the large variation of the
patient conditions and of the method-
ology of the articles reviewed, as
described above, made it impossible
to statistically combine the results of
studies which are so heterogeneous.
Consequently, a meta-analysis could
not be made (Jadad 2000). Thus, in
an attempt to organize the information
obtained, we have established four
methodological models, in which it is
possible to classify and study the art-
icles reviewed:
Model 1. The ‘over-the-counter’ (OTC)
model
In the OTC model, patients with
gingivitis received the electric or
manual toothbrush as the only treat-
ment, with standardized instructions,
without any professional modification
of their habits of oral hygiene (Table 4).
Results which were difficult to
explain were seen in the first study of
1962 (Chilton et al. 1962), in which
a worsening in both groups was
observed. Only two short-term studies
(2/4) showed significant differences in
the reduction of gingival bleeding or
inflammation (Lobene 1964, Stoltze &
Bay 1994), and only one of these in
the reduction of plaque (Stoltze & Bay
1994).
We have included the data of
patients without instruction in oral
hygiene of the study by McKendrick
et al. (1968), as they are the only avail-
able long-term information in this
model. No significant differences were
seen in the reduction of the indicators
of the periodontal status or the plaque
index in these patients (Table 4).
Model 2. The ‘oral hygiene instruction’
(OHI) model
In this model professional inter-
vention was already produced by the
provision of education, motivation
and modification of the patients oral
hygiene habits (Table 5). Some studies
even added systems of control of
compliance with the oral hygiene proto-
col, such as a system of telephone
calls and cards (Baab & Johnson 1989,
Johnson & McInnes 1994, Khocht
et al. 1992, Killoy et al. 1989).
Significantly greater reductions of
gingival bleeding or inflammation
were observed with electric tooth-
brushes in four short-term studies (4/8):
two with counter-rotational brushes
(Baab & Johnson 1989, Killoy et al.
1989), one with an oscillating-rotating
brush (van der Weijden et al. 1998b)
and one with an ultrasonic brush
(Terezhalmy et al. 1994). In the first
three studies the reduction of the gin-
gival parameters was accompanied by
a significantly similar behaviour of
the plaque index, with approximate
values of 60–80% in the reduction from
baseline plaque levels (Table 5).
On the other hand, in another four
articles (4/8), we found no differences
or greater reductions of these par-
ameters in the control group. Of these

Table 3. Baseline relative values of gingival bleeding or inflammation and plaque in the selected studies
Bleeding-gingivitis Baseline bleeding- Plaque index Baseline plaque
Study index (scale) gingivitis % scale (scale) % scale
Ainamo et al. (1997) GBI (%) 40 VPI (%) 54.40
Baab and Johnson (1989) GBI (%) 71.4 OPCR (%) 76
Chilton et al. (1962) PMA (0–27) 24.10 CI (1 to 3) 55
Forgas-Brockmann et al. GI (0–3) 56.3 PI (0–5) 58
(1998)
Heasman et al. (1999) GI (0–3) 52 PI (0–5) 31
Johnson and McInnes (1994) GBI (%) 63.70 PI (0–5) 35.80
Khocht et al. (1992) GI (0–3) 41 PI (0–5) 44.60
Killoy et al. (1989) TBI (0–3) 34.70 PI (0–5) 49.60
Killoy et al. (1993) TBI (0–3) 11.60 PI (0–5) 57.40
Lobene (1964) PMA (*) * * *
Love (1993) TBI (0–3) 8.16 OPCR (%) 80.70
McKendrick et al. (1968) RPI (0–6) * ODI (0–3) 62.7
O’Beirne et al. (1996) GI (0–3) 59.3 * *
Quirynen et al. (1994) SBI * Q-HPI *
Stoltze and Bay (1994) BSI (%) 12.5 VP1I (%) 35
Terezhalmy et al. (1995) GI (0–3) 31.3 PI (0–5) 42.5
Tritten and Armitage (1996) BOP (%) 41.6 PI (0–5) 54.2
van der Weijden et al. (1994) BA (0–2) 80 PI (0–5) 33.4
van der Weijden et al. (1998) BMPI(0–2) 65 PI (0–5) 55.6
Walsh et al. (1989) BOP (%) 43.5 VP1I (%) 54
Yukna & Shaklee (1993) BOP (%) 14.3 PI (0–5) 22.8
Scale, range of values in each index; Baseline bleeding-gingivitis % scale, baseline relative value of bleeding or gingivitis expressed as the
percentage of the maximum value of the scale employed (index) to measure it; Plaque % scale, baseline relative value of bleeding or gingivitis
expressed as the percentage of the maximum value of the scale employed (index) to measure it.
*There are no data or it is not possible to calculate the information.
 46
Sicilia et al.

Table 4. Studies made with the over-the-counter (OTC) model (OTC = absence of professional education or modification of the oral hygiene habits of the patient)
B-G/plaque B-G baseline-reduction % B-G % plaque
Study Duration Indexes Group B-G baseline B-G end of study end of study reduction reduction
Chilton et al. (1962) 2 months PMA/CI Test: Broxodent1 5.9 7.2
1.3
22.0 5.9
Control: Manual brush 6.4 7.7
1.3
20.3 6.3
‘‘standard brush’’
Forgas-Brockmann et al. 1 month EBI/PI Test: Ultra-sonex1 0.76 0.56 0.2 26.3 0.09
(1998) CC Control: Manual brush 0.9 0.69 0.19 24.1 0.06
Oral-B1
Lobene (1964) 3 months PMA Test: General Electric1 69.11 39.84 29.27 42.3 *
Control: Manual brush1 69.3 67.23 2.07 3.0{ *
Oral-B 40 advantage
Stoltze & Bay (1994) 1.5 months BSI/VPLI Test: Braun D5 PC1 12.4 3.2 9.2 74.2 79.8
Control: Manual brush 12.7 11 1.7 13.4{ 24.2{
Tandex1
McKendrick et al. (1968) 24 months RPI ODI Test: Ronson1 Control: 0.80 0.50 0.30 37.5 23.9
(Oral hygiene Manual brush Gibb’s 0.71 0.40 0.31 43.7 20.7
uninstructed patients) Short-head Med. 1
B-G, bleeding or gingivitis; CC, compliance-controlled; PMA, PMA index of gingivitis; CI, Chilton cleanliness index; EBI, Eastman bleeding index; PI, Turesky plaque index; BSI, % of sites with
bleeding to stroking or showing ‘spontaneous’ bleeding, codes 2 or 3 of the Löe and Silness gingival index (GI); VPLI, % of sites with ‘visible plaque’, codes 2 or 3 of the Silness and Löe plaque index
(P1I), Broxodent1, Electric brush (Broxodent1); Ultra-sonex1, Ultrasonic electric brush (Ultra-sonex1); General Electric1, General Electric reciprocating electric brush; Braun D5 PC1,
oscillating-rotating electric brush (Braun D5 Plak Control1).
*No data.
{Statistically significant difference between test and control (numbers in bold indicate the most favourable result).
Table 5. Studies made with the oral hygiene instruction (OHI) model (OHI ¼ professional education or modification of the oral hygiene habits of the patient)
B-G/Plaque B-G B-G baseline-end % B-G % plaque
Study Duration indexes Group baseline B-G end of study of study reduction reduction reduction
Baab & Johnson (1989) 1 month GBI Test: Interplak1 69.9 46.5 23.4 33.5 63.6
CC OPCR Control: manual brush 72.8 56.2 16.6 22.8{ 33.3{
Butler 4111
Johnson & McInnes 1 month GBI Test: Sonicare1 57.5 40.7 16.8 29.2 25.8
(1994) CC PI Control: manual brush 71.6 45.9 25.7 35.9 8.8
Oral-B 301
Khocht et al. (1992) 1 month GI Test I: Epident1 1.25 1.01 0.24 19.2 21.5
CC PI Test II: Interplak1 1.21 1.06 0.15 12.4 18.9
Control: manual brush 1.26 0.99 0.27 21.4 15.5
Oral-B 40 advantage1
Killoy et al. (1989) 1 month BMBI Test: Interplak1 1.01 0.23 0.78 77.2 82
CC PI Control: manual brush 1.07 0.6 0.47 43.9{ 59.9{
‘‘conventional brush’’
O’Beirne et al. (1996) 2 months MPBI Test: Sonicare1 Control: 1.85 0.43 1.42 76.8 *
manual brush Oral-B1 1.87 0.53 1.34 71.7 *
Terezhalmy et al. (1995) 1 month EBI Test: Ultra-sonex1 0.45 0.18 0.27 60
40.8
PI Control: manual brush 0.40 0.44
0.04
10{
53.7
Oral-B1
Tritten & Armitage 1 month BOP Test: Sonicare1 Control: 41.2 29.9 11.3 27.4 20.7
(1996) CC PI manual brush Butler 3311 42 24.3 17.7{ 42.1 19.1
Van der Weijden et al. 1 month BMPI Test: Braun Oral-B 3D1 1.32 0.33 0.99 75 79.5
(1998) PI Control: manual brush 1.28 0.55 0.73 57{ 64.8{
Butler GUM 3111
McKendrick et al. (1968) 24 months RPI Test: Ronson1 0.77 0.52 0.25 32.5 16.2
ODI Control: manual brush 0.80 0.32 0.48 60 25.8
Gibb’s Short-head med1
B-G, bleeding or gingivitis; CC, compliance-controlled; GBI, Ainamo & Bay modified gingival bleeding index; OPCR, O’Leary plaque control record; PI, Turesky plaque index; GI, Löe and Silness
gingival index; BMBI, Barnett-Mühlemann bleeding index; MPBI, modified papillary bleeding index; EBI, Eastman bleeding index; BOP, bleeding on probing; BMPI, bleeding on marginal probing
index; RPI, Russell Periodontal Index; ODI, Greene and Vermilion oral debris index; Interplak1, Counter-rotational electric brush (Interplak1); Sonicare1, Test, Sonic electric brush (Sonicare1);
Epident1, Oscillating-rotating,-three heads electric brush (Epident1); Ultra-sonex1, ultrasonic electric brush (Ultra-sonex1); Braun Oral-B 3D1, oscillating-rotating electric brush (Braun Oral-B
3D1); Ronson1, arcuate movement electric brush (Ronson1).
*No data.
{Statistically significant difference between test and control (numbers in bold indicate the most favourable result).
Powered vs. manual toothbrushes in cause-related therapy
47
48 Sicilia et al.
studies, three were made with sonic
toothbrushes (Johnson & McInnes
1994, O’Beirne et al. 1996, Tritten &
Armitage 1996). The only study with
long-term data also showed a greater
reduction in the manual group in this
type of patient (McKendrick et al.
1968). In this second lot of studies,
which do not show a better response
in the test group, no significant dif-
ferences in the reduction of plaque
between the patients with electric or
manual toothbrushes were seen either,
and the approximate values of reduc-
tion with respect to the baseline plaque
levels ranged between 16% and 26%.
Model 3. The ‘prophylaxis and oral hygiene
instruction’ (POHI) model
In the POHI model, patients are
instructed in oral hygiene by a pro-
fessional and received a prophylaxis
after the initial examination (Table 6,
studies indicated as POHI). Only two
articles mentioned the use of proced-
ures for controlling the compliance
with the oral hygiene protocol
(Heasman et al. 1999, van der Weijden
et al. 1994).
In the three short-term studies no
marked differences were observed
among the patients using electric or
manual toothbrushes. Only in one
of these was a greater reduction of
gingival bleeding seen in the test
group (Quirynen et al. 1994), while in
another the two groups behaved simi-
larly (Love et al. 1993). Finally, an
increase in the gingival inflammation
was detected in all the groups of
the third study (Heasman et al. 1999).
In these articles no significant differ-
ences were seen in the reduction of
plaque, which is maintained in small
values, the reduction in the range 3–24%.
As an exception, in one of these an
increase of 33% in the baseline–end-of-
study plaque values is seen in the control
group (Quirynen et al. 1994).
In the long-term studies, significant
reductions of gingival bleeding were
seen in the two articles selected, both
with a oscillating-rotating type of brush
(Ainamo et al. 1997, van der Weijden
et al. 1994), although only in the second
of these was a concomitant significant
reduction of plaque observed (Table 6).
Model 4. The ‘supportive periodontal
treatment’ (SPT) model
In this model, long-term studies in
patients who have suffered moderate
periodontal disease and have required
treatment, and received prophylaxis and/
or subgingival scaling every 3 months,
were included (Table 6, studies indi-
cated as SPT).
In the three articles selected, a
greater significant reduction was seen
in gingival bleeding and dental plaque
in the test group. Two of these (2/3)
employed a counter-rotational tooth-
brush (Killoy et al. 1993).
Appearance of gingival recessions,
abrasions and complications
Only two of the selected studies
specifically evaluated the appearance
of gingival recessions (Johnson &
McInnes 1994, McKendrick et al.
1968). The first of these, which
employed a sonic brush, registered the
presence of recessions at 6 months,
while the second evaluated its incidence
over 2 years using an electric brush
with an arcuate movement. No
increase of recessions was seen in any
of the cases, nor were there any
differences with respect to the control
groups.
Various articles recorded the occur-
rence of gingival abrasions. The
majority (6/8) showed no significant
differences (Baab & Johnson 1989,
Heasman et al. 1999, Johnson &
McInnes 1994, Terezhalmy et al.
1994, van der Weijden et al. 1994,
Walsh et al. 1989). One study made
with counter-rotational brushes found
four localized abrasions in 20 cases
compared with two out of 20 in the
control group. Another article, in which
the effect of sonic brushes was evalu-
ated, reported that these are even less
abrasive than manual ones (Tritten &
Armitage 1996).
Discussion
The results of the evolution of gingi-
val bleeding and inflammation in the
21 studies analysed show considerable
variation, this ranging from an
increase of 22% to a reduction of
86.7% with respect to baseline values
in the groups with electric tooth-
brushes. This lack of consistency is
also observed in the control group,
in which it ranges from an increase
of 20% to a reduction of 72%
(Tables 4–6). Thus, in general terms,
it is very difficult to make a global
evaluation of the efficacy of electric
toothbrushes as part of the treatment
of gingivitis.
The influence of the characteristics and
baseline status of the population
The efficacy of a measure of oral
hygiene is highly related to the cap-
acity of the sample population to
become motivated, to receive instruc-
tion, and to develop and comply with
a correct brushing technique. For this
reason some authors avoid studies
using dental students, because the
excellent response that could be
expected in the test and control
groups may hamper the finding of
significant differences (Ainamo et al.
1997, Stoltze & Bay 1994). In this way
we have found, although the informa-
tion of the sample in the studies is
fairly limited, that the majority of
authors have selected patients from the
general population, supportive peri-
odontal treatment programs, or non-dental
university students (Tables 1 and 2).
The severity of the baseline peri-
odontal disease could condition the
results of the study. It has been sug-
gested that smaller improvements could
be seen in patients who present a
lesser degree of gingival inflammation
at the beginning of the investigation
(Love et al. 1993). In our review, only
in one article was the severity of the base-
line disease classified as mild gingivitis
(McKendrick et al. 1968), and in this no
significant differences were found. How-
ever, if we analyse (Table 3) the articles
with a baseline relative value of gingival
bleeding or inflammation of less than
15% (Killoy et al. 1993, Stoltze & Bay
1994, Yukna & Shaklee 1993a), we find
that significant differences were found in
these three cases (Tables 4 and 6). These
data are not conclusive, as there are
many factors which can affect this obser-
vation. Nevertheless, many authors try
to homogenize the baseline characteris-
tics of the study population, either with
strictly defined inclusion criteria, analys-
ing the baseline differences among the
groups, at least for the main outcome
variable (19/21), or even harmonizing
the severity of the disease present at
the beginning of the study, by means
of an experimental gingivitis proto-
col (van der Weijden et al. 1998b).
From our point of view the baseline
status of the participants is more
important than the inclusion criteria:
the relevant information being the
severity of the baseline gingival bleed-
ing or inflammation of the whole
sample and of each treatment group,
and also the distribution of well
Table 6. Studies made with the prophylaxis and oral hygiene instruction model (POHI), and the supportive periodontal treatment model (SPT)
B-G baseline-end % B-G % plaque
Study Duration B-G/plaque indexes Group B-G baseline B-G end of study of study reduction reduction reduction
Heasman et al. (1999) 1.5 months GI Test I: Phillips J 2-A1 1.44 1.49
0.05
3.5 16.1
POHI PI Test II: Braun O. B D71 1.44 1.61
0.17
11.8 17.7
Control: manual brush 1.47 1.64
0.17
11.6 5.6
Oral-B 35 advantage1
Love et al. (1993) 2 months BMBI Test: Interplak1 0.245 0.125 0.115 49.0 18.2
POHI OPCR Control: manual brush 0.245 0.120 0.120 49.0 23.8
Butler 311 GUM1
Quirynen et al. (1994) 3 months SBI Test: Interplak1 * * * 77.6 3.5
POHI Q-HPI Control: manual brush * * * 63.8
33.1
Oral-B 301
Ainamo et al. (1997) 12 months GBI Test: Braun Oral B PC1 40.9 19.8 21.1 51.6 34.5
POHI VPI Control: manual brush 39.1 24.4 14.7 37.6{ 30.5
Jordan soft1
Van der Weijden 8 months BA Test: Braun PC1 1.63 0.69 0.94 57.7 41.9
et al. (1994) POHI PI Control: manual brush 1.56 0.89 0.67 42.9{ 25.2{
Butler GUM 3111
Killoy et al. (1993) 18 months BMBI Test: Interplak1 0.45 0.06 0.39 86.7 72.7
SPT PI Control: manual brush 0.23 0.17 0.06 26.1{ 46.9{
‘manual toothbrush’
Walsh et al. (1989) 6 months BOP Test: Broxo1 49 31 18 36.7 61.0
SPT VPLI Control: manual brush 38 28 10 26.3{ 59.2{
Oral-B 401
Yukna & Shaklee 6 months BOP Test: Interplak1 15.3 8.5 6.8 44.4 63.0
(1993) SPT PI Control: manual brush 13.2 11.0 2.2 16.7{ 38.0{
‘conventional brush’
B-G, bleeding or gingivitis; GI, Löe and Silness gingival index; PI, Turesky plaque index; BMBI, Barnett-Mühlemann bleeding index; OPCR, O’Leary plaque control record; SBI, Mühlemann and
Son sulcus bleeding index; Q-HPI, Quigley and Hein plaque index; GBI, Ainamo & Bay modified gingival bleeding index; VPI, Ainamo & Bay visible plaque index; BA, bleeding assessment; BOP,
bleeding on probing; VPLI, % of sites with ‘visible plaque’, codes 2 or 3 of the Silness and Löe plaque index (PlI); SPT patients, supportive periodontal therapy patients; Phillips J 2-A1, oscillating-
rotating electric brush (Phillips Jordan 2-Action1); Braun O. B D71, oscillating-rotating electric brush (Braun Oral B D71); Interplak1, counter-rotational electric brush (Interplak1); Braun Oral B
PC1, Oscillating-rotating electric brush (Braun Oral B Plak Control1); Braun PC1, oscillating-rotating electric brush (Braun Plak Control1); Broxo1, oscillating electric brush (Broxo1).
*No data.
{Statistically significant difference between test and control (numbers in bold indicate the most favourable result).
Powered vs. manual toothbrushes in cause-related therapy
49
50 Sicilia et al.
known prognostic factors among
them. If this is not borne in mind we
can find, as has occurred in three of
the articles (Johnson & McInnes 1994,
Killoy et al. 1993, Walsh et al. 1989),
significant baseline differences for
the outcome variable, or for the prog-
nostic factors, which will seriously
affect the interpretation of the results.
With the data available we cannot
conclude that the type of population,
or its level of baseline disease, could
condition the results in one sense or
another. However, it would be desir-
able if the sample information were
more complete, and include the
following:
* mean age and range of the sample;
* description of the type of patients;
* severity of the baseline periodontal
disease of the participants;
* comparability between treatment
groups in relation to the main out-
come variables.
This will improve the quality of the
studies and facilitate their comparison
in future systematic reviews.
Reduction of gingival bleeding or
inflammation
With the aim of analysing the informa-
tion obtained in the most homo-
geneous way possible, we have designed
four methodological design models,
based on the hygienic and perio-
dontal treatment received by the patient,
and on their periodontal status. The
information derived from short and
medium, and long-term studies has
been borne in mind for each group.
The ‘over-the-counter’ and the ‘oral hygiene
instruction’ models (OTC and OHI)
In the first group (OTC) (Table 4), the
studies were designed with similar
conditions to those when buying an
electric toothbrush in a chemist’s
shop and using it without previous
professional education or modifica-
tion of hygiene habits (Stoltze & Bay
1994). On the other hand, in the
second (OHI), patients received meticu-
lous instructions and their normal
hygiene behaviour was changed. This
effect was occasionally reinforced with
follow-up measures of compliance to
such (Table 5). The main point which
differentiates these groups from each
other is the intervention in the oral
hygiene of the patient, as several
studies appear to indicate that an
excessive control of this could lead
to a considerable improvement in the
parameters of plaque and gingivitis,
which could mask the effect of the
type of toothbrush and make it
difficult to find differences among
groups (Love et al. 1993, Stoltze & Bay
1994). One of the studies reviewed
(McKendrick et al. 1968), with a 2-year
follow-up, has four treatment groups,
two with instructions on oral hygiene
and two without; no significant
differences were found among groups,
either in the periodontal status or
in the reduction of dental plaque.
This could indicate that the effect
of instruction in oral hygiene is not
so important. Nevertheless, in our
review the OTC and OHI models
appear to behave differently. In the
OTC, excluding the patients of
McKendrick et al. (1968), only one
study achieved a considerable reduction
of plaque (79.8% in the test group),
the rest of the values being less
than 7% (Table 4). While in the OHI
model three investigations found
values of a large reduction in plaque
(63.6–82% in the test group), and
the rest ranged around 20% (Table 5).
However, the same behaviour is not
seen when we consider the variable
reduction of gingival bleeding or
inflammation. In the OTC group two
studies found significant reductions in
the patients using powered toothbrushes
(2/4), and this occurs in the same
proportion in the studies of the OHI
group (4/8).
The use of measures to assure com-
pliance with the oral hygiene protocol
does not appear to influence the
appearance of significant differences
of gingival bleeding or inflammation
or the relative reduction of dental
plaque (Table 5). Five studies of the
OHI model presented systems of control
of compliance with their oral hygiene
protocol. In three of these no import-
ant reductions of dental plaque were
achieved (20–25% in the test group)
and therefore no significant improve-
ments in the gingival bleeding or
inflammation were detected. On the
other hand, the opposite was seen in
two studies, in which the reduction
of plaque was of greater magnitude
(63–82% in the test group).
In both models we found six studies
which endorse the efficacy of electric
toothbrushes, the majority having in
common a considerable and concomi-
tant reduction, different from the
rest of the non-significant studies, of
the dental plaque in the test group
(4/5). One study presented no data
on the reduction of plaque (Lobene
1964). Of these studies four had been
made with oscillating-rotating and
counter-rotational brushes (Tables 4
and 5).
The ‘prophylaxis and oral hygiene
instruction’ and ‘supportive periodontal
treatment’ models (POHI and SPT)
In the remaining models (Table 6) a pro-
fessional intervention already existed
by means of prophylaxis (the POHI
model) or supportive periodontal
treatment (the PST model). In the
POHI model at least one prophylaxis
was done after the initial exploration,
supposedly in order to harmonize the
level of plaque and gingival inflamma-
tion among treatment groups. It has
been suggested previously that the
possible therapeutic effect of such
may be so considerable that it could
mask the effect of the electrical brush
(Ainamo et al. 1997, Stoltze & Bay
1994). This concept can be reinforced
by the fact that no significant differ-
ences in gingival bleeding or inflam-
mation, and plaque were found in any
of the POHI short-term studies. How-
ever, in the remaining two long-term
studies, both made with oscillating-
rotating brushes, significant differen-
ces in gingival bleeding were seen
(Ainamo et al. 1997, van der Weijden
et al. 1994). This different behaviour
observed in the short- and long-term
studies can be explained as, in the
former, relatively lower reductions of
dental plaque were observed (3–18%
in the test group of the short-term
studies vs. 34–42% in the same group
of the long-term ones). We must bear
in mind that two of these short-term
investigations were made with counter-
rotational brushes, with which in the
OHI model, greater reductions of
the plaque of 62–83% were achieved
(Table 5).
Finally, in the SPT model the three
studies obtained significant reduc-
tions of gingival bleeding and dental
plaque (Table 6). It is noteworthy
that, similar to other previous cases,
important reductions in the plaque
were observed (61–72% in the test
group), and that two out of three of

these investigations were made with
counter-rotational brushes (Killoy
et al. 1993, Yukna & Shaklee 1993a).
Efficacy of different types of powered
toothbrushes
It is impossible to draw concrete con-
clusions in relation to the efficacy of
the specific types of electric tooth-
brush. However, excluding the short-
term articles included in the POHI
model, which did report significant
differences, we have observed certain
tendencies on analysing the 10 studies
(10/18) which detected significant dif-
ferences between the groups. Firstly,
the oscillating-rotating brushes have
demonstrated their efficacy in the
reduction of gingival bleeding in four
studies: in the OTC model (Stoltze &
Bay 1994), in the OHI model (van der
Weijden et al. 1998b), and in the long-
term POHI model (Ainamo et al.
1997, van der Weijden et al. 1994).
In these a reduction of gingival bleed-
ing of between 0.35 and 4.5 times
greater in the test group than in the
controls was achieved. At the same
time they showed a reduction in the
plaque (not significant in the study of
Ainamo et al. (1997)), which was
between 0.13 and 2.3 times greater in
the test group (Tables 4 and 6). Sec-
ondly, the counter-rotational brushes
have demonstrated their efficacy equally
in four studies: two in the OHI model
(Baab & Johnson 1989, Killoy et al.
1989), and two in the SPT model
(Killoy et al. 1993, Yukna & Shaklee
1993a). In this case the reduction
of gingival bleeding observed was bet-
ween 0.47 and 2.32 times greater in
the test group than the control group,
and the reduction of plaque was
between 0.37 and 0.91 times greater in
the test group (Tables 4 and 6).
The ultrasonic and sonic brushes
have not demonstrated their efficacy
in the present review. The ultrasonic
brushes have been studied in two
models of OTC (Forgas-Brockmann
et al. 1998) and the OHI (Terezhalmy
et al. 1994). The first of these studies
found no significant differences bet-
ween the groups, and, paradoxically,
the second, which detected a significant
reduction of gingival bleeding of 60%
in the test patients, simultaneously
observed an increase of bleeding of
10% in the control group, and an
increase of between 40% and 54% of
plaque in both of them. Three studies
Powered vs. manual toothbrushes in cause-related therapy
have evaluated the efficacy of sonic
brushes, all in the OHI model
(Johnson & McInnes 1994, O’Beirne
et al. 1996, Tritten & Armitage 1996).
In the first two, no significant differ-
ences were found in gingival bleeding
between the groups, while the third
favours the manual brush. This absence
of efficacy is associated with a small
reduction of plaque, which is only
significant in the study of Johnson &
McInnes (1994) (Tables 4–6).
It appears that some evidence exists
which supports the use in certain
circumstances of electric toothbrushes,
especially oscillating-rotating and
counter-rotational ones. However, this
information should be analysed with
caution given the commercial implica-
tions. In this sense it is surprising
that in the two studies in which
an oscillating-rotating or counter-
rotational brush is used as a positive
control, that is, in the two studies in
which the objective was not to
demonstrate their efficacy, signifi-
cant reductions in the periodontal
parameters or dental plaque were not
detected in their favour (Heasman
et al. 1999, Khocht et al. 1992),
contrary to that previously described.
Similarly, paradoxical data are seen
on observing the selection of manual
brushes for the control group, as no
study employs a manual toothbrush
of the same company as that of the
electrical toothbrush it is evaluating,
using on occasions that of the pos-
sible competitor (Ainamo et al. 1997,
Heasman et al. 1999).
Reduction of dental plaque
Of all the values which, from a meth-
odological point of view, we related
to the reduction of gingival bleeding
or inflammation, the reduction of
dental plaque is the parameter which
behaves in the most consistent way.
In the studies in which a difference of
significant reduction in favour of the
electric toothbrushes has been detected
(10/21), we have observed significant
reductions of plaque. Of the nine
studies which provide data on the
reduction of plaque, excluding the
difficult-to-explain results of Terezhalmy
et al. (increase of the plaque index
of 40–54% in both groups), we found
considerable reductions in two studies
(of 34.5% and 41.9% in the test
group) (Ainamo et al. 1997, van der
51
Weijden et al. 1994), and very con-
siderable ones in seven (61–82% in
the test group) (Baab & Johnson
1989, Killoy et al. 1993, Killoy et al.
1989, Stoltze & Bay 1994, van der
Weijden et al. 1998b, Walsh et al.
1989, Yukna & Shaklee 1993a).
On the other hand, in the rest
of the investigations which did not
detect significant differences between
the groups in favour of electric
toothbrushes, that is, which failed
to disprovethe null hypothesis, the
reduction of plaque is much smaller
and ranges, ruling out extreme
data, between 5.9 and 25.8% (Tables 4
and 6).
Appearance of gingival recessions and
complications
One of the secondary objectives of
this review has been to evaluate, in
the selected studies, the appearance
of complications, fundamentally in
the form of gingival recessions or
abrasions. We did not find evidence
that electric toothbrushes can cause
greater tissue damage than manual
brushes employed as controls.
Use of different indexes
On trying to quantitatively analyse
the data in this systematic review of
the literature, we have found a variety
and multiplicity of the indexes
employed (Tables 1 and 2). Only in
these tables have we included 23
indexes of gingival bleeding or inflam-
mation, and plaque. A certain ‘con-
sensus’ in relation to the use of plaque
indexes exists, the most commonly
used (11/21) being that of Turesky
(PI), while among the gingival bleed-
ing or inflammation indexes we have
observed a greater variety. However,
in 16 out of the 21 studies indexes of
gingival bleeding were employed, the
most common (3/16) being that of
bleeding on probing (BOP).
The use of a variety of ordinal type
scales, in which the differences bet-
ween the consecutive values are not
mathematically equivalent, makes it
impossible to combine studies with
different measures in a meta-analysis
(Jadad 2000). It would be desirable if
the next systematic review, which
could be made in a few years to detect
the evidence from 2002 onwards in
this field, does not experience the
same problems. A homogenization
52 Sicilia et al.
of the indexes to be employed in the
future will therefore be necessary. The
solution to this could be the consensus
of ‘a minimum of common indexes’
(for example, the BOP and the PI),
which each author should employ
besides those which are more adapted
to their methodological design and
objectives.
Methodological limitations
From the methodological point of
view, certain errors have been detected,
which have been previously described.
However, it would be convenient
if the authors, in accordance with
the recommendations of CONSORT
(http://www.consort-statement.org):
1 made an effort to define in a com-
plete form the baseline characteris-
tics and status of the participants in
the investigation;
2 present complete global informa-
tion for the outcome variables of
all patients, and of those included
in each group, at the beginning and
end of the study;
3 clearly report the analyses made, dif-
ferentiating those which had been
previously prespecified from those
exploratory (Moher et al. 2001).
We have detected that a need for
studies exists which permits us to
respond to the question formulated
as the aim of this systematic review
in a quantitative evidence-based way.
For this, and bearing in mind that the
use of an electric toothbrush is the
treatment of a complete patient, it is
important that future studies made to
test the efficacy of powered tooth-
brushes, even if they are designed to
clarify any secondary objectives (for
example its efficacy in certain sub-
groups), provide global data of all
the patients included in the manual
and electrical group at the beginning
and end of the study. From a scien-
tific point of view it does not make
much sense to dedicate resources and
effort to answer secondary questions,
when the fundamental one is not
answered.
Conclusions
Implications for practice
The dentist can prescribe the use of
a power-driven toothbrush as an
Table 7. Summary of the comparisons between power-driven and manual toothbrushes in
reduction of gingival bleeding or inflammation
Power-driven Better power- No Better manual Difficult to
toothbrushes driven brush differences brush interpret results
Oscillating/rotating 4 1* 0 0
Counter-rotational 4 1* 0 1*
Sonic 0 2 1 0
Ultrasonic 0 1 0 1
Others 2 3 0 0
*Studies made with the POHI model.
associated tool in cause-related which will permit us to evaluate in
therapy based on the evidence below a quantitative way and on patient-
(See table 7). based data, the efficacy of electric
toothbrushes in the reduction of
1 Limited evidence exists of the
gingival bleeding or inflammation
higher efficacy of electric tooth-
and dental plaque.
brushes compared with manual
2 It is important in these studies that
ones to reduce gingival bleeding or
the socio-demographic, health, and
inflammation. This appears to be
periodontal characteristics of the
related to their capacity to eliminate
participants, including the baseline
dental plaque.
global values of the principal vari-
2 Limited evidence exists of the
ables of the study, are described in
higher efficacy of oscillating-rotating
a precise way. This will facilitate
brushes, compared with manual ones,
the generalization of the results
in the reduction of gingival bleeding
and the combination of such in
or inflammation and plaque in
future systematic reviews.
patients with moderate gingivitis or
3 It is necessary that these studies
periodontitis. This been supported by
employ common scales of measure-
four studies: two made in the short
ment (indexes) for the quantitative
term, with and without professional
analysis of future systematic
intervention in the oral hygiene habits
reviews. We propose the consensus
of the patients, and two in the long term.
of some common minimum indexes
3 Limited evidence exists on the
which should be included in each
higher efficacy of counter-
study. From the data of this review
rotational brushes in the reduction
it can be deduced that these could
of gingival bleeding or inflammation
be bleeding on probing (BOP) and
and plaque in patients with mild
the plaque index of Turesky (PI).
gingivitis or periodontitis. This been
4 From the methodological point of
supported by four studies: two made
view the use of a model with pro-
in the short-term with professional
fessional intervention in the oral
intervention in the oral hygiene
hygiene habits of the patient, or
habits of the participants, and two
even the use of measures of control
long-term studies in patients under
of ‘compliance’, that is, the design of
supportive periodontal treatment.
what some authors have called ‘over-
4 We have not been able to detect
controlled studies’, does not appear
evidence which permits us to dem-
to negatively affect the possible
onstrate the higher efficacy of ultra-
appearance of significant differences
sonic and sonic brushes in the reduction
between groups. However, this is
of gingival bleeding or inflamma-
not so clear in short-term studies
tion, and dental plaque in patients
in which a prophylaxis is employed
with gingivitis or periodontitis.
after the initial examination.
5 In relation to the absence of effi-
Implications for research cacy of the ultrasonic and sonic
brushes, it is necessary to make fur-
1 There is a need for studies made ther investigations, critically analysing
with a homogeneous methodology, the study designs employed up to

the present. It is therefore necessary
to clarify to what extent study
limitations can be responsible for the
small reduction of plaque observed
in both test and control groups.
Acknowledgments
We wish to thank Maurizio Tonetti
and Ian Needleman for their invaluable
support and advice during the prep-
aration of this review, and David H.
Wallace for the English language
revision.
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Address:
Dr Alberto Sicilia
Section of Periodontology
Clı́nica Universitaria de Odontologı́a
Facultad de Medicina
Universidad de Oviedo
Catedrático José Serrano sn.
33006 Oviedo
Spain
Tel: þ34 98 5103641
e-mail: asicilia@clinicasicilia.com