Electric Toothbrushes

Electric Toothbrushes–
For Whom are They Designed?
Sebastian Ciancio
Department of Periodontology, SUNY-Buffalo, 250 Squire Hall, 3435
Main St., Buffalo, NY 14214-3008; ciancio@buffalo.edu
Adv Dent Res 16:6-8, May, 2002
Abstract — Powered toothbrushes were first introduced on a
large scale in the early 1960s. However, because of a clear lack
of superiority compared with manual brushes, and problems
with mechanical breakdowns, their sales decreased
significantly. However, recommendation for their use
continued in special populations with dexterity and cognition
problems. The 1990s ushered in an era of new technology, and
studies began to suggest superiority of some powered brushes,
particularly those using oscillating-rotating or counterrotational actions. Some studies have shown interproximal
cleansing abilities superior to those of manual brushes and
yielding results similar to those achieved with the use of a
manual brush and floss. Both controlled and open-labeled
studies have suggested that electric brushes improve gingival
health with patients who routinely used manual brushes prior
to using these new powered brushes, and safety has been
clearly established. In recommending powered toothbrushes,
practitioners should familiarize themselves with the products
available, with the clinical studies supporting their benefits
compared with manual brushes, their safety and ease of use,
and the patient's economic status.
T
he first electric toothbrush is reported to have
been introduced in 1938 but, due to technical
problems, was withdrawn from the market place
(Rosenthal, 1962).
Powered toothbrushes with an arcurate or reciprocal
motion were first introduced in the early 1960s, but because of a
clear lack of superiority and problems with mechanical
breakdown, they were not widely available in the marketplace
by the end of that decade (Frandsen, 1986; Bader, 1992).
However, recommendation for their use continued for a limited
population—mainly those with mental or physical impairments
and for persons with reduced manual dexterity. Also, studies
supported a recommendation for use in orthodontic patients
(Kobayashi and Ash, 1954; Boyd et al., 1989).
In 1986 an international workshop on oral hygiene
concluded that powered toothbrushes were not as good as
manual brushes (Frandsen, 1986). Because of this, these
brushes remained limited to the same populations as occurred
in the late ‘60s.
The 1990s ushered in an era of new technology for electric
brushes, resulting in unique instruments that were of benefit in
a broader population. A report by Brothwell et al. (1998)
reviewed the various electric brushes available as of December,
1998, and evaluated the scientific evidence for these brushes and
their value to the general population. They concluded that there
is good evidence to recommend toothbrushing twice daily...and
for using oscillating—rotating or counter-rotational action
electric toothbrushes. The report also highlighted benefits in
orthodontic patients. They went on to say that there is moderate
evidence to recommend using a soft-bristled manual
toothbrush, thus suggesting a benefit for the general population
for using electric brushes compared with manual brushes.
An interesting part of their report went on to state that there is
moderate evidence recommending against the use of vibrating,
rotating, or sonic action brushes. They based this recommendation
on a lack of superiority of these products compared with manual
brushes and stated that the added cost did not justify their use.
Another population to consider for use of an electric brush is the
patient who does not clean well interproximally. A 12-month
study showed that a rotating brush gave results equal to those
achieved with the use of a manual brush and interproximal
cleaning aids (Glavind and Zeuner, 1986). Other powered brushes
of various designs have also been shown to be superior to manual
brushes in the removal of interproximal plaque (Yukna and
Shaklee, 1993a,b; Ciancio et al., 1994; Cronin et al., 1998).
However, the practitioner must weigh his or her decision
based on the literature relative to each product and on
developments since 1998 on various product designs and
improvements. Further, in reaching a decision, the practitioner
must rely on claims supported by human clinical studies and
not by animal or laboratory data.
A recent article by Barnes (1998) suggests that powered
toothbrushes should be a primary recommendation, rather than
a secondary alternative, for all patients (Barnes, 1998). This
suggestion is good as long as the patient can afford the product. I
say this for the following reasons: I was in a pharmacy a few
weeks ago in my home town of 35,000 people and stood at the
checkout counter and watched what happened to manual
toothbrushes being sold for 3/$1.00. Practically everyone bought
one, with mothers buying multiples of 3. It should be noted that
in this town the unemployment rate is high, wages are low, and
there are many working poor, as in many other towns across
America. Therefore, family economics must also be a factor in
toothbrush recommendations.
In her review, Barnes goes on to say, “Since the size and
design of some electric toothbrushes are not appropriate for
some patients, dental hygienists should try one for feasibility
and thoroughly familiarize themselves with exactly how each
brush works in their hands.” She also states that other features
should be considered, such as warranty, cost, and availability
of replacement heads.
Use in Children
Another important population to consider is children. In one
early study, Lefkowitz et al. (1962) compared the use of an
electric toothbrush with that of a manual brush in two groups
of children, one group aged between 7 and 9 years, and
another group between 10 and 12 years, and found that, in
both groups, more plaque was removed by the electric brush.
In contrast, a crossover study involving children with a mean
age of 4.28 years compared use of an electric and a manual
toothbrush; there were no statistically significant differences
between the two groups with respect to plaque removal,
although plaque reduction in the electric toothbrush group
was somewhat greater than that with the manual brush
(Owen, 1972). Other studies have shown that electric
toothbrushes are valuable for children with mental handicaps
(Kelner, 1963) and those with poor manual dexterity (Smith
and Blankenship, 1964), while a more recent study in normal
healthy children, 8-12 years of age, showed superiority of a
reciprocating, oscillating brush over manual brushes in this
population (Grossman and Proskin, 1997).
Key Words
Toothbrushes, powered, manual, clinical studies, safety.
Presented at a Symposium entitled "Powered Toothbrushes: Hype or
Science?", sponsored by the IADR Oral Health Research Group and
held during the 78th General Session of the International Association
for Dental Research, April 5-8, 2000, Washington, DC
Downloaded from adr.sagepub.com at PENNSYLVANIA STATE UNIV on September 11, 2016 For personal use only. No other uses without permission.
6
Copyright 2002 by the International/ American Associations for Dental Research
Practice-based Data
The majority of studies in the literature have been from
university- or research-based centers and have been wellcontrolled. An interesting deviation from this design occurred
when a practice-based survey of German dentists was conducted
by the manufacturer of the most frequently sold electric brush in
that country, a reciprocating, oscillating device (Braun Oral B
Plaque Remover, Gillette Inc., Boston, MA, USA) (Warren et al.,
1998). Three hundred ninety-nine dentists were contacted. Many
dentists in Germany (41%) thought that between half and 70% of
their patients did not clean their teeth correctly, and that this is the
result of either poor brushing technique or insufficient brushing
time, coupled with insufficient visits to the dentist. Most dentists
(61%) surveyed stated that they would recommend an electric
toothbrush to their patients to improve oral hygiene control, and
of these, 82% would recommend the reciprocating, oscillating
brush. When these dentists were asked if there had been any
change in tooth and gum condition among those patients who
switched from using a manual toothbrush to the powered brush,
73% said that they had observed an improvement. None of the
dentists interviewed had noted any deterioration in gingival
health. This experience reflects exactly what happened in my
practice. We recommend three electric brushes in our practice,
each with a different action and all from reliable manufacturers.
After switching several of our patients to electric brushes and
blinding ourselves as to who they were, we noted a marked
improvement, 3 months and 6 months later, in oral hygiene and
gingival health in 85% of our patients (age range, 48-80 yrs).
A large practice-based study was conducted in the United
States and published recently in the Journal of the American
Dental Association. This study evaluated the effectiveness of a
power toothbrush (again, the Braun Oral B Plaque Remover) in
over 16,000 patients, the majority of whom were manual brush
users before receiving the power brush (Warren et al., 2000).
In summary, the authors concluded that “the power brush
was considered by dental professionals to have had a positive
effect on the oral health of 80.5% of their patients...” Most
patients in the study (88.9%) reported that they would
continue using the power brush after the study was completed.
When an electric brush is being recommended to a specific
group of patients, compliance is a consideration. In the 1960s,
compliance was less than 50% (Stalnacke et al., 1995) after 6
months. However, two well-controlled recent studies showed
compliance in the 70-80% range, particularly in periodontal
patients who had been historically poorly compliant with oral
hygiene instructions (Muhler, 1969; Hellstadius et al., 1993).
Another point to consider is that some electric brushes
reach certain areas of the mouth better than other areas.
Therefore, in patients with selective plaque problems, this
point should be considered in the selection of an electric brush
for that area. Additionally, some electric brushes remove stain
better than manual brushes, so heavy stainers (smokers, coffee
and tea drinkers) may benefit from them.
Safety
Generally, the literature on safety falls into four categories
(Fischman, 1998):
(1) Studies that have measured the effect of the powered
toothbrush on gingivitis. A positive effect on gingivitis, or
the lack of a negative finding, would suggest that the
device is not injurious to gingival health.
(2) Safety studies that consist of an oral hard- and soft-tissue
examination, performed at regular intervals during a
clinical trial, and a subjective summary at the conclusion.
These oral examination procedures generally follow the
recommendations of the American Dental Association
(American Dental Association Guidelines, 1996).
(3) Patient satisfaction surveys. It can safely be assumed that
patients would not prefer a product that they perceived as
injurious to their gingival health or that provoked gingival
or dental pain.
(4) Studies designed to assess tooth sensitivity. A lack of
sensitivity would indicate minimal or no removal of tooth
structure.
The major safety concerns expressed in the literature relative
to both manual and powered brushes have been related to:
• Bristle hardness
• Force applied
• Methodology of the dentifrice
• Abrasiveness
The major clinical concerns of improper brushing with abrasives are:
• Soft-tissue abrasion
• Gingival recession
• Cervical wear
• Dentinal hypersensitivity
The American Dental Association’s 1996 Guidelines for
Toothbrushes state that it is generally accepted that powered
toothbrushes “automatically confer on the user good brushing
technique that most would never achieve with a manual
toothbrush” (Fischman, 1998). Further, a leading European
clinical investigator, Dr. Ainamo, has stated, “unfortunately,
for a significant proportion of the general population the ideal
situation does not exist and it is for these patients, plus those
with poor manual dexterity, that the electric toothbrush may
offer the greatest advantage” (Ainamo et al., 1997).
In conclusion, it can be stated that, in the new century,
electric brushes are of value for a variety of populations
because (a) they generally provide a good brushing technique
regardless of the ability of the user, and (b) they can improve
patient motivation and encourage long-time compliance.
However, not all electric brushes are better than manual
brushes, and clinicians must be aware of this fact in
recommending electric brushes.
References
Ainamo J, Zie Q, Aimano A, Kallio P (1997). Assessment of the
effect of an oscillating/rotating electric toothbrush on oral
health. A 12-month longitudinal study. J Clin Periodontol
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American Dental Association Guidelines (1996). Chicago, IL: ADA
Council on Scientific Affairs, January.
Bader HJ (1992). Review of currently available battery operated
toothbrushes. Compend Cont Educ Dent 13:1163-1169.
Barnes CM (1998). Powered toothbrushes: evidence warrants
wider recommendations. Access 12(5):56-60.
Boyd RL, Murray P, Robertson PB (1989). Effect of a rotary electric
toothbrush versus manual toothbrush on periodontal status
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Brothwell DJ, Jutai DKG, Hawkins RJ (1998). An update of
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novel electric toothbrush (Braun Oral-B Plaque Remover) with
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Fischman SL (1998). Review of published safety data: Braun OralB® Plaque Remover Toothbrush. Periodontal Insights Sept:17-19.
Frandsen A (1986). Mechanical oral hygiene practices: state-of-thescience review. In: Dental plaque control measures and oral
hygiene practices. Löe H, Kleinman D, editors. Washington,
DC: IRL Press, pp. 93-116.
Downloaded from adr.sagepub.com at PENNSYLVANIA STATE UNIV on September 11, 2016 For personal use only. No other uses without permission.
Adv Dent Res 16:6-8, May, 2002
For
Whom are Powered Toothbrushes Designed?
Copyright 2002 by the International/ American Associations for Dental Research
7
Glavind L, Zeuner E (1986). The effectiveness of a rotary electric
toothbrush on oral cleanliness in adults. J Clin Periodontol
13:135-138.
Grossman E, Proskin H (1997). A comparison of the efficacy and
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8
Ciancio
Copyright 2002 by the International/ American Associations for Dental Research
Adv Dent Res 16:6-8, May, 2002