IJCPD
10.5005/jp-journals-10005-1310
Comparison of Effectiveness of Manual Orthodontic, Powered and Sonic Toothbrushes
Research Article
Comparison of Effectiveness of Manual Orthodontic,
Powered and Sonic Toothbrushes on Oral Hygiene
of Fixed Orthodontic Patients
1
Ruchi Sharma, 2Mridula Trehan, 3Sunil Sharma, 4Vikas Jharwal, 5Nidhi Rathore
ABSTRACT Keywords: Fixed orthodontic treatment, Manual orthodontic
toothbrush, Oral hygiene, Powered toothbrush, Sonic tooth-
Introduction: Maintenance of good oral hygiene is important brush.
for patients undergoing fixed orthodontic treatment.
How to cite this article: Sharma R, Trehan M, Sharma S,
Aim: The aim of this study was to evaluate the effectiveness Jharwal V, Rathore N. Comparison of Effectiveness of Manual
of a manual orthodontic toothbrush, powered toothbrush with Orthodontic, Powered and Sonic Toothbrushes on Oral
oscillating head and sonic toothbrush in controlling plaque, Hygiene of Fixed Orthodontic Patients. Int J Clin Pediatr Dent
gingivitis and interdental bleeding in patients undergoing 2015;8(3):181-189.
fixed orthodontic treatment, and to compare their relative Source of support: Nil
efficacy.
Conflict of interest: None
Materials and methods: Sixty subjects, who were to receive
orthodontic treatment with both upper and lower fixed appli-
INTRODUCTION
ances, were randomly divided into three study groups, with 20
patients in each group. Groups I to III were given manual ortho Maintenance of good oral hygiene is important for patients
dontic, powered and sonic toothbrushes, respectively. Plaque undergoing fixed orthodontic treatment. Fixed appliance
index (PI), gingival index (GI) and interdental bleeding index
components, such as bands, brackets, wires and ligatures
were scored to assess the level of plaque accumulation, gingival
health and interdental bleeding at baseline; 4 and 8 weeks recall
trap food and debris which leads to plaque accumulation.
visits after fixed appliance bonding. Paired t-tests and one-way This frequently aggravates gingivitis, probing pocket
analysis of variance (ANOVA) tests were used for intragroup depth, hyperplastic tissue, decalcification, dental caries
and intergroup comparisons. The level of statistical significance and white spot lesions on the coronal surfaces of teeth.1-4
was set at p < 0.05. Thus, it is essential to achieve adequate plaque control
Results: This study showed that a significant reduction in all in such patients.
the three indices scores was found from baseline to 4 and 8 Regular tooth brushing is advised routinely to pat-
weeks in group III. On intergroup comparison, no statistically ients undergoing fixed orthodontic therapy as a means
significant differences were detected between the three groups
of preventing gingival and dental disease.5 Since, various
for any of the parameters assessed.
types of toothbrushes are available in the market with
Conclusion: On intragroup comparison, sonic brushes per- attractive appeal, there is a need for sound clinical
formed superiorly in reducing gingivitis, plaque and interdental research to evaluate their effectiveness in order to guide
bleeding as compared to the manual orthodontic and powered
professional recommendations for orthodontic patients.
brushes. On intergroup comparison, the relative comparative
effectiveness was found to be similar for all the three brushes. Numerous clinical and laboratory studies have been
conducted in patients receiving fixed orthodontic treat-
ment which compared the effectiveness of different types
1
Postgraduate Student (Third Year), 2,3
Professor and Head of manual and powered toothbrushes with conventional
4,5
Senior Lecturer and advanced designs. However, the results were found
1,2,4,5
Department of Orthodontics and Dentofacial Orthopedics to be conflicting. Therefore, this study attempts to find
Mahatma Gandhi Dental College and Hospital, Jaipur, Rajasthan out the relative comparative effectiveness of various
India
types of toothbrushes, i.e. manual orthodontic tooth-
3
Department of Oral and Maxillofacial Surgery, Mahatma
brush, powered toothbrush with oscillating head and
Gandhi Dental College and Hospital, Jaipur, Rajasthan, India
sonic toothbrush. In controlling plaque, gingivitis and
Corresponding Author: Ruchi Sharma, Postgraduate Student
(Third Year), Department of Orthodontics and Dentofacial interdental bleeding in patients undergoing fixed ortho-
Orthopedics, Mahatma Gandhi Dental College, Jaipur dontic treatment; and compare their relative efficacy by
Rajasthan, India, Phone: 9461752741, e-mail: [Link]@ evaluating the relationship between the oral hygiene
[Link]
status before and during treatment.
International Journal of Clinical Pediatric Dentistry, September-December 2015;8(3):181-189 181
Ruchi Sharma et al
MATERIALS AND METHODS • Previous or current use of powered or manual ortho-
dontic toothbrushes
This study was a randomized clinical trial carried out in the
• Gross caries lesions
department of orthodontics and dentofacial orthopedics,
• Diagnosed with early onset periodontitis
Mahatma Gandhi Dental College, Jaipur.
• Smoking, tobacco products
Once the approval from the local ethical committee
• Pregnancy
of the institution had been obtained, 60 systematically
• Acute illness.
healthy subjects were recruited for the study and divided
The brushes evaluated in the study were (Fig. 1):
into the following three groups (n = 20):
• Manual orthodontic brush: Colgate Ortho [Colgate
Group I: Six males, 14 females; who were given manual
Palmolive (India) ltd.]
orthodontic brushes, the mean age was found to be
• Battery powered toothbrush with oscillating head: Colgate
17.9 years with a range of 13 to 25 years.
360˚ whole mouth clean [Colgate Palmolive (India) ltd.]
Group II: Eleven males, 9 females; who were given
• Battery powered sonic toothbrush: Colgate 360˚ sonic
powered brushes, the mean age was found to be 20.6
power [Colgate Palmolive (India) ltd.]
years with a range of 13 to 28 years.
With these brushes, each individual was issued a
Group III: Nine males, 11 females; who were given
fluoride-containing toothpaste (Colgate, Colgate-Palmo-
sonic powered brushes, the mean age was found to be
live (India) ltd,) free of antiplaque or anticalculus agents
19.25 years with a range of 12 to 32 years.
(Fig. 2). Oral hygiene instructions with demonstrations
A written informed consent was obtained from each
on a set of plastic models of the dental arches with upper
patient for participating in the study.
and lower fixed appliances were given to all the patients.
All the patients were instructed to brush twice a day for a
Inclusion Criteria
• Patients who were to receive fixed orthodontic treat-
ment with upper and lower preadjusted edgewise
appliance therapy simultaneously
• At least 20 teeth present in the oral cavity
• Minimum 16 brackets or bands on teeth
• Brushing habit of at least once per day
• Age between 13 and 32 years
• No use of antibiotics in the past 2 months
• Absence of menstruation or pregnancy at the time of
recording scores.
Exclusion Criteria
• Presence of a systemic disease
Fig. 1: Toothbrushes used in the study: manual orthodontic,
• Use of antibiotics, steroids or nonsteroidal anti- powered and sonic
inflammatory drugs (NSAIDs) therapy within past
2 months or during the study
• Fewer than five teeth per quadrant
• Immunosuppressant drugs
• Medically compromised
• Mentally handicapped subjects
• Subjects with poor manual dexterity
• Poor compliance subjects
• Subjects who received oral hygiene instructions from
dental professional in past 6 months
• Presence of severe gingival inflammation
• No obvious periodontal disease (systemic or local) or
attachment loss or pocketing
• Use of antibacterial mouth rinses
• Juvenile/aggressive periodontitis Fig. 2: Toothpaste used in the study
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Comparison of Effectiveness of Manual Orthodontic, Powered and Sonic Toothbrushes
2-minute time period, in the morning, and before retiring
at night. A digital timer (Fig. 3), a toothbrushing booklet
with printed instructions and a planner were also issued
to each patient. The use of interproximal brushes, dental
floss, mouth rinses or any other mechanical or chemical
cleaning aids was not permitted during the study.
Manual orthodontic brush with short heighted central
bristles and ‘v’ cut design was used by group I patients
for effective cleaning of areas in and around orthodontic
brackets and archwires. Patients were instructed to use
their toothbrush with a combination of rolling (or sweep-
ing) and vibration technique as advocated by Wockmock
and Guay.6
For the powered and sonic toothbrushes, in groups II
Fig. 4: Clinical assessment tools and instruments
and III, the manufacturer’s recommendations were follo-
wed. The purpose and design of the toothbrush were also
discussed. Patients were instructed how to place and
move their powered toothbrush so as to clean one tooth
at a time. Scrubbing motion of toothbrushing was used on
occlusal surfaces for all the three types of toothbrushes.
After receiving oral hygiene instructions followed
by professional prophylaxis (scaling and polishing), pre-
adjusted edgewise fixed orthodontic labial appliances
were directly bonded on all erupted teeth, except for the
1st and 2nd molars which were generally banded.
The clinical examinations were then carried out and
scores for gingival, plaque and interdental bleeding indi-
ces were recorded at baseline, 4 and 8 weeks. Throughout
the entire study, patients were examined by a single
Fig. 5: Scoring PI at mesial zone of labial tooth surface at baseline
examiner to minimize inter-examiner bias.
Following placement of a self-retaining cheek retrac-
tor and cotton rolls, the teeth were dried with compressed
air and then all the indices were recorded (Figs 4 to 11).
At baseline, plaque was assessed with the help of an
explorer on the labial or buccal surfaces of the teeth, on
which the fixed appliance was to be bonded, or banded
using the plaque index (PI) originally described by Silness
Fig. 6: Scoring PI at middle zone of labial tooth surface at baseline
and Loe.7 Gingivitis was measured with a periodontal
probe (Williams periodontal probe) on the labial or buccal
surfaces of the teeth at baseline, 1st and 2nd visit using
the gingival index (GI) described by Loe and Silness.8
Interdental gingival bleeding was determined by East-
Fig. 3: Digital timer man’s interdental bleeding index.9
International Journal of Clinical Pediatric Dentistry, September-December 2015;8(3):181-189 183
Ruchi Sharma et al
Fig. 7: Scoring PI at distal zone of labial tooth Fig. 8: Scoring GI at mesial zone of labial tooth
surface at baseline surface at baseline
Fig. 9: Scoring GI at middle zone of labial tooth Fig. 10: Scoring GI at distal zone of labial tooth
surface at baseline surface at baseline
Fig. 11: Scoring interdental bleeding index at baseline Fig. 12: Scoring GI at distal zone of labial tooth surface at 4 and
8 weeks
At 4 and 8 weeks recall visits after fixed orthodontic
appliance bonding, patients were reassessed (Figs 12 Statistical Analysis
to 19) and also questioned if they experienced any soft or Statistical analysis was performed using Statistical Package
hard-tissue trauma from brushing by the allocated brush. for Social Sciences (SPSS) software version 17. Paired t-test
Plaque was assessed on the labial or buccal surfaces of was used for intragroup comparisons. One-way analysis of
teeth, using the orthodontic modification of the Silness variance (ANOVA) was used for intergroup comparison.
and Loe PI as described by Williams et al.10 The level of statistical significance was set at p < 0.05.
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Comparison of Effectiveness of Manual Orthodontic, Powered and Sonic Toothbrushes
Fig. 13: Scoring GI at middle zone of labial tooth surface at Fig. 14: Scoring GI at mesial zone of labial tooth surface at
4 and 8 weeks 4 and 8 weeks
Fig. 15: Scoring PI at zone mesial to the bracket margin at Fig. 16: Scoring PI at zone distal to the bracket margin at
4 and 8 weeks 4 and 8 weeks
Fig. 17: Scoring PI at zone gingival to the bracket margin at Fig. 18: Scoring PI at zone incisal to the bracket margin at
4 and 8 weeks 4 and 8 weeks
RESULTS The mean scores of all the three indices at baseline, 4
and 8 weeks are represented by line diagrams in Graph 2
The mean scores of all the three indices for all the study for group I, Graph 3 for group II and Graph 4 for group III.
groups with standard deviation are shown in Table 1 and Intragroup comparisons of GI, PI and Eastman’s inter-
as histogram in Graph 1. dental bleeding index scores within each study group
International Journal of Clinical Pediatric Dentistry, September-December 2015;8(3):181-189 185
Ruchi Sharma et al
Fig. 19: Scoring interdental bleeding index at 4 and 8 weeks Graph 2: Gingival index, PI and EIBI for group I (ortho manual)
from baseline to 4 and 8 weeks
from baseline to 4 weeks (T0–T1), baseline to 8 weeks
(T0–T2) and from 4 to 8 weeks (T1–T2) as done by paired
t-test with associated p values are shown in Table 2.
Intergroups comparisons among the three study
groups in mean changes from baseline to 4 weeks (T0–T1),
Table 1: Mean scores of all indices in each study group from
baseline to 4 and 8 weeks
Baseline (T0) 4 weeks (T1) 8 weeks (T2)
mean scores mean scores mean scores
Indices (SD) (SD) (SD)
Orthomanual
GI 1.10 (0.10) 1.05 (0.04) 1.05 (0.04)
PI 1.16 (0.17) 1.05 (0.04) 1.06 (0.04)
EIBI 0.23 (0.19) 0.15 (0.07) 0.13 (0.06)
Powered
GI 1.08 (0.16) 1.05 (0.13) 1.04 (0.13) Graph 3: Gingival index, PI and EIBI for group II (powered) from
PI 1.12 (0.21) 1.05 (0.13) 1.04 (0.13) baseline to 4 and 8 weeks
EIBI 0.18 (0.19) 0.08 (0.07) 0.09 (0.06)
Sonic
GI 1.09 (0.19) 1.04 (0.17) 1.04 (0.17)
PI 1.12 (0.24) 1.04 (0.17) 1.04 (0.17)
EIBI 0.19 (0.18) 0.10 (0.07) 0.09 (0.06)
Graph 4: Gingival index, PI and EIBI scores for group III (sonic)
from baseline to 4 and 8 weeks
baseline to 8 weeks (T0–T2) and from 4 to 8 weeks (T1–T2)
for GI, PI and Eastman’s interdental bleeding index scores
Graph 1: Histogram showing mean scores of all the indices as done by one-way ANOVA with associated p-values are
from baseline to 4 and 8 weeks shown in Table 3.
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Comparison of Effectiveness of Manual Orthodontic, Powered and Sonic Toothbrushes
Table 2: Intragroup comparison for GI, PI and EIBI scores in was found from baseline to 4 and 8 weeks (p < 0.05).
each study group by paired t-test from baseline to 4 and 8 weeks No statistically significant reduction in GI scores was
Intragroup comparisons observed at any point of time. The reduction of EIBI scores
Indices T0–T1 p-value T0–T2 p-value T1–T2 p-value from baseline to 4 weeks was found to be significant for
Orthomanual this group which was no longer significant at 8 weeks
GI 0.05 0.02 NS 0.05 0.07 NS 0.00 0.63 NS
follow-up. This may be due to the large size of the head
PI 0.11 0.05* 0.10 0.05* –0.01 0.78 NS
which made it hard to maneuver into interdental areas.
EIBI 0.08 0.09 NS 0.10 0.03* 0.02 0.09 NS
Powered
In group III, for whom sonic brushes were allocated, a
GI 0.03 0.08 NS 0.04 0.06 NS 0.01 0.49 NS significant reduction in PI, GI and EIBI scores was found
PI 0.07 0.01* 0.08 0.005* 0.01 0.60 NS from baseline to 4 weeks and from baseline to 8 weeks
EIBI 0.10 0.05* 0.09 0.15 NS –0.01 0.47 NS (p < 0.05).
Sonic Grossman et al suggested that the superior perfor-
GI 0.05 0.005* 0.05 0.02* 0.00 0.51 NS mance of sonic brush may be attributed to sonic waves
PI 0.08 0.04* 0.08 0.05* 0.00 0.87 NS
produced by the brush which can remove adherent bacte-
EIBI 0.09 0.003* 0.10 0.002* 0.01 0.70 NS
rial plaque and disrupt bacterial growth and significantly
*p < 0.05: Statistically significant; NS: Non significant
reduce inflammation.11 The reason for the reductions in
Table 3: Intergroup comparison for mean change in GI, PI and EIBI scores was elevated cleaning tip, extended outer
EIBI scores from baseline to 4 and 8 weeks among the study bristles and tightly packed center bristles of sonic brush
groups by one-way ANOVA
used in our study, which provided better interproximal
Intergroup comparisons
cleaning with sonic vibrations.
Duration Orthomanual Powered Sonic p-value
No statistically significant differences were found in
Mean difference scores with SD
Gingival index PI, GI and EIBI scores from 4 to 8 weeks for all the study
T0–T1 0.05 (0.10) 0.03 (0.10) 0.05 (0.10) 0.77 NS groups.
T0–T2 0.05 (0.10) 0.04 (0.10) 0.05 (0.10) 0.94 NS On intergroup comparison, no statistically significant
T1–T2 0.00 (0.04) 0.01 (0.04) 0.00 (0.04) 0.66 NS differences were detected among all the study groups for
Plaque index any of the parameters assessed like GI, PI or EIBI scores
T0–T1 0.11 (0.24) 0.07 (0.18) 0.08 (0.18) 0.81 NS when mean differences from T0 to T1, T0 to T2 and T1 to
T0–T2 0.10 (0.23) 0.08 (0.18) 0.08 (0.18) 0.86 NS
T2 were compared. This shows that all the three tooth-
T1–T2 –0.01 (0.07) 0.01 (0.06) 0.00 (0.06) 0.85 NS
brushes were found to be equally effective in controling
Eastman’s interdental bleeding index
T0–T1 0.08 (0.18) 0.10 (0.18) 0.09 (0.18) 0.94 NS plaque, gingivitis and interdental bleeding in patients
T0–T2 0.10 (0.19) 0.09 (0.19) 0.10 (0.19) 0.98 NS undergoing fixed orthodontic treatment.
T1–T2 0.02 (0.09) –0.01 (0.09) 0.01 (0.09) 0.92 NS This is in accordance with some studies where it was
NS: p > 0.05, i.e. statistically not significant found that powered toothbrushes with a normal brush
head or with an orthodontic brush head were as effective
DISCUSSION
as manual toothbrushes in removing plaque or very few
The results obtained from this study showed that in improvements with regard to plaque and in bleeding on
group I for whom manual orthodontic toothbrush was probing were noticed with the use of powered tooth-
given, a statistically significant reduction in PI scores brushes as compared with manual toothbrushes.5,12-15
was found from baseline to 4 and 8 weeks (p < 0.05). No However, there are no conclusive results in the literature
statistically significant difference was found in GI scores as per the results of reviews done by D’costa et al and
obtained at any point of time. This may be due to the fact Robinson et al.16,17
that patients took time to adapt to an orthodontic tooth- On the other hand, some studies have found powered
brush after fixed appliance bonding and the technique of and sonic/ultrasonic brushes to be superior over manual
placing its outer bristles at an angle of 45° to the gumline. ones in plaque removal.10,18-22 Despite reduced plaque
A significant reduction in Eastmen interdental bleeding scores found in such power brush trials, improvements
index (EIBI) was noticed at 8 weeks follow-up. This may in the gingival health of fixed appliance patients are not
be attributed to its longer and softer outer bristles and very much convincing.23
smaller head design than that of an ordinary or conven- A comparative study of use of manual and powered
tional medium sized manual toothbrush, which provided toothbrushes in orthodontic patients done by Borutta et al
better interproximal cleaning. and Silvestrini et al showed a statistically significant posi-
In group II, for whom powered brushes were tive variation in plaque and gingival scores with use of
allocated, a statistically significant reduction in PI scores powered brushes.21,24 But, these studies were short-term
International Journal of Clinical Pediatric Dentistry, September-December 2015;8(3):181-189 187
Ruchi Sharma et al
trials. Sicilia et al in a review advocated that there is clear 4. Mizrahi E. Enamel demineralization following orthodontic
need of long-term trials in this field.25 treatment. Am J Orthod 1982;82(1):62-67.
5. Hickman J, Millett DT, Sander L, Brown E, Love J. Powered
In our study, no tissue trauma or any dental or gingival
versus manual toothbrushing in fixed appliance patients: a
abrasion was noted on the gums after 8 weeks of using short-term randomized controlled clinical trial. Angle Orthod
the powered and sonic toothbrushes. These findings 2002;72(2):135-140.
confirm the safety aspects of powered toothbrushes.26 6. Womack WR, Guay AH. Comparative cleansing efficiency
Another factor influencing toothbrush recommenda- of electric and a manual toothbrush in orthodontic patients.
tion is cost. The price of a manual orthodontic brush is Angle Orthod 1968;38(3):256-267.
7. Silness J, Loe H. Periodontal disease in pregnancy II.
relatively less. However, powered brushes may be advan-
Correlation between oral hygiene and periodontal condition.
tageous for certain populations that have increased diffi- Acta Odontol Scand 1964;22:121-135.
culty in maintaining oral hygiene (e.g. poor compliance 8. Loe H, Silness J. Periodontal disease in pregnancy I. Preva-
patients, mentally challenged, children and younger lence and severity. Acta Odontol Scand 1963;21:533-551.
patients, etc.). 9. Caton JG, Polson AM. The interdental bleeding index: a sim-
plified procedure for monitoring gingival health. Compend
As this study included human subjects, the influence
Contin Educ Dent 1985;6(2):88-90.
of the ‘Hawthorne effect’ must be considered. The Haw- 10. Williams P, Clerehugh V, Worthington HV, Shaw WC. Com-
thorne effect is expected to be greatest when the novelty parison of two plaque indices for use in fixed orthodontic
device is used first. In the present study, this was not appliance patients. J Dent Res 1991;70:703.
observed because scores of plaque and gingival indices 11. Grossman E, Dembling W, Proskin HM. A comparative clini-
at the end of 8 weeks were lower or equal than the scores cal investigation of the safety and efficacy of an oscillating/
rotating electric toothbrush and a sonic toothbrush. J Clin
at the end of 4 weeks.
Dent 1995;6(1):108-112.
12. Costa MR, Silva VC, Miqui MN, Sakima T, Spolidorio DM,
CONCLUSION Cirelli JA. Efficacy of ultrasonic, electric and manual tooth-
brushes in patients with fixed orthodontic appliances. Angle
The conclusions of the present study are as follows:
Orthod 2007;77(2):361-366.
• On intragroup comparison, sonic brushes performed 13. Thienpont V, Dermaut LR, Van Maele G. Comparative study
superiorly in reducing gingivitis, plaque and interdental of 2 electric and 2 manual toothbrushes in patients with fixed
bleeding as compared to the manual orthodontic and orthodontic appliances. Am J Orthod and Dentofac Orthop
powered brushes. 2001;120(4):353-360.
• On intergroup comparison, all the three toothbrushes, 14. Heintze SD, Jost-Brinkmann PG, Loundos J. Effectiveness of
three different types of electric toothbrushes compared with
i.e. manual orthodontic, powered and sonic tooth-
a manual technique in orthodontic patients. Am J Orthod
brushes were found to be equally effective in con- Dentofac Orthop 1996;110(6):630-638.
trolling plaque, gingivitis and interdental bleeding 15. Nathoo S, Mankodi S, Mateo LR, Chaknis P, Panagakos F.
in patients undergoing fixed orthodontic treatment. A clinical study comparing the supragingival plaque and
The relative comparative effectiveness was found to gingivitis efficacy of a specially engineered sonic powered
toothbrush with unique sensing and control technologies to
be similar for all the 3 brushes.
a commercially available manual flat-trim toothbrush. J Clin
Thus, any of the three brushes can be recommended Dent 2012;23 Spec no. A:A11-A16.
for orthodontic patients in order to maintain their oral 16. D’costa K, Dana R, IP G, Kong E, Vol I. Electric versus manual
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17. Robinson P, Deacon SA, Deery C, Heanue M, Walmsley AD,
effectiveness of different types of toothbrushes with
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International Journal of Clinical Pediatric Dentistry, September-December 2015;8(3):181-189 189