Volume 73 Number 7

770
Six-Month Comparison of Powered Versus
Manual Toothbrushing for Safety and
Efcacy in the Absence of Professional
Instruction in Mechanical Plaque Control
Andrew R. Dentino,* Gay Derderian,* MaryAnn Wolf,* MaryAnn Cugini,

Randy Johnson,

Ronald L. Van Swol,* Dennis King,

Pam Marks,

and Paul Warren

Background: Reports suggest powered toothbrushing may provide some clinical benet over manual tooth-
brushing, but most studies have been of short duration with subjects trained in toothbrush use. The aim was
to determine if the oscillating-rotating powered brush (PB) could safely provide clinical benets over and above
a manual brush (M) in subjects with no formal instruction or experience in powered brush use.
Methods: This 6-month, single-masked, parallel design, randomized clinical trial compared the PB with an
American Dental Association (ADA)-accepted soft-bristle manual brush in a non-ossing gingivitis population
(n = 157). Subjects were given written instructions but no demonstration on toothbrush use at baseline. Ef-
cacy was assessed by changes in gingival inammation, plaque, calculus, and stain, while changes in clini-
cal attachment levels and recession measurements provided safety data. A prophylaxis was provided after base-
line assessment. The 6-month plaque index (PI) was recorded immediately post-brushing after covert timing
of the subjects, and correlation analyses were run to assess the relationship of brushing time to PI. Paired t
tests, analysis of variance (ANOVA), and analysis of covariance (ANCOVA) were used to assess within and
between treatment group differences for PB (n = 76) versus M groups (n = 81).
Results: Measures of inammation showed a statistically signicant drop for both brushes at 3 and 6 months.
Mean overnight full-mouth PI scores were signicantly lower at 3 months for the PB (1.57) compared to the
M group (1.80), P = 0.0013. Immediate post-brushing PI at 6 months was also signicantly lower for the PB
(1.10) versus M (1.39) (P = 0.0025). There was an overall negative correlation for PI and brushing time (r =
0.377, P = 0.0001). Mean calculus index (CI) scores were lower for the PB at 3 (P = 0.0304) and 6 months
(P = 0.0078), while no signicant differences in stain were observable. Clinical attachment level and reces-
sion measurements showed no signicant between-group changes from baseline for either brush on canine
teeth or on teeth with recession at baseline.
Conclusion: The oscillating-rotating toothbrush safely provides clinical benefits in plaque and calculus
reduction over a manual brush even in subjects with no formal oral hygiene instruction. J Periodontol 2002;
73:770-778.
KEY WORDS
Clinical trials; dental calculus/prevention and control; gingival recession/prevention and control;
gingivitis/prevention and control; dental plaque/prevention and control; toothbrushing; dental devices,
home care.
* Marquette School of Dentistry, Milwaukee, WI.
Braun/Oral B, Boston, MA.
Marquette School of Dentistry; deceased.
StatKing Consulting, Cincinnati, OH.
Currently, Braun/Oral B, Boston, MA; previously, Braun/Oral B, Kronberg, Germany.
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J Periodontol July 2002 Dentino, Derderian, Wolf, et al.
771
T
he 1996 AAP World Workshop consensus report
on prevention suggested limited evidence exists
that powered toothbrushing may provide an addi-
tional benet over manual toothbrushing.
1
Reviews by
Saxer and Yankell
2,3
provide additional support for this
view. It is generally accepted that professional oral
hygiene instruction is necessary to get the maximum
benet from any device used for mechanical plaque
control. In addition, questions have been raised regard-
ing the potentially deletrious effects of improper tooth-
brush use on gingival margin position.
4,5
Several studies document that it is difcult to deter-
mine a signicant difference between powered or man-
ual toothbrush efcacy in short-term studies (2 months
or less) if no professional instruction is given.
6,7
In
contrast, when oral hygiene instruction is provided,
the newer powered brushes tend to show signicantly
better plaque removal or inflammation reduction in
studies up to 12 months.
8-11
In reality, most tooth-
brushes are purchased outside dental ofces with no
professional instruction or demonstration available to
the consumer. For powered brushes in particular, the
extent of instruction is often limited to the manufac-
turers written directions. Moreover, several studies sug-
gest that inappropriate use of a toothbrush may lead
to gingival recession.
4,12,13
The specic aims of this
study were 2-fold. First, to determine if a powered
toothbrush (PB) could be used safely in an adult pop-
ulation with no previous experience using a powered
brush and no instruction other than that available in
the packaging. Second, to compare the efcacy of the
PB and manual (M) brush in reducing gingival inam-
mation and plaque, and inhibiting calculus and stain
formation.
MATERIALS AND METHODS
Study Population
Medically healthy subjects between 18 and 65 years
of age were recruited primarily by newspaper adver-
tisement. Entry criteria included mild to moderate gin-
givitis, a minimum of 20 natural teeth, and no previ-
ous experience using a powered toothbrush. Individuals
who were pregnant or lactating were excluded. One
hundred and seventy-two subjects met the screening
criteria and signed the informed consent approved by
the Marquette University Human Subjects Institutional
Review Board. One hundred and fty-seven of these
subjects nished the trial and the data presented are
for only these subjects. The demographics of this pop-
ulation are listed in Table 1. The 15 subjects who did
not nish the trial either could not be contacted, had
moved, or were unwilling to complete the study.
Study Design (Figure 1)
The study protocol was approved by the Marquette
University Institutional Review Board and patients were
subsequently screened by a periodontist to confirm
the presence of gingivitis as determined by modied
gingival index (MGI)
14
of at least 1.2 and/or 20% or
more sites showing bleeding on probing. Based on the
screening visit, patients were stratied by gender, MGI,
plaque index (PI), and smoking using a computer pro-
gram,

and were randomly assigned to the 2 experi-

mental groups at baseline with odd numbered subjects
assigned to the powered brush group and the even
numbered subjects to the manual group, with the
exception that members of the same household were
assigned to the same brush. After clinical measure-
ments were made, the subjects received either an oscil-
lating-rotating powered toothbrush
#
(PB = 76) or the
ADA-accepted standard soft-bristle manual toothbrush
**
Figure 1.
Outline of study protocol.
Microsoft Excel, Microsoft Corp, Redman, WA.
# D9, Ultra Plaque Remover, Braun/Oral B, Kronberg, Germany.
** ADA Reference Standard Toothbrush, ADA, Chicago, IL.
Table 1.
Study Population Characteristics
Total Powered Group Manual Group
(n = 157) (n = 76) (n = 81)
Mean age 31.8 32.2 31.8
Age range 18-61 18-61 18-59
Male 53 28 25
Female 104 48 56
Smoker (Yes) 29 11 18
Caucasian 85 41 44
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Powered Versus Manual Toothbrushing Volume 73 Number 7
(M = 81). Powered brush users were advised to read
and follow the manufacturers instructions for use while
the manual brush group was provided an ADA pam-
phlet on how to brush. All subjects were given uoride
toothpaste

and were asked to brush for 2 minutes

twice a day, and to refrain from ossing or using any
other toothbrush/toothpaste or mouthrinses during the
study. No timer was provided to the manual brush
users to more closely simulate home care conditions;
the powered brush had a built-in timer. No further
instructions regarding mechanical plaque control tech-
nique were given to subjects throughout the study, and
they were reminded not to speak with any of the clin-
icians regarding their toothbrush. Volunteers received
a prophylaxis at the end of the baseline appointment
such that no visible stain or calculus remained. Sub-
jects returned to the clinic at 3 months for an oral
exam, clinical measurements, and brush/brush head
and toothpaste replacement. Six months after base-
line the clinical measurements were repeated. At this
visit, subjects were required to bring their brush and,
out of sight of the examiner, they brushed their teeth
prior to the PI assessment. Subjects were not speci-
cally instructed to brush for 2 minutes at this visit.
Rather, they were asked to brush until they felt their
teeth were clean, as they had done at home. A large
clock with a second hand was placed directly above
the sink, to see if subjects would naturally brush for a
full 2 minutes. The brushing times were recorded with-
out their knowledge.
Clinical Examination and Prophylaxis
Safety assessment. At each visit the subjects were
rst seen for an oral safety exam and specic probing
measurements carried out by a single examiner using
one batch of calibrated UNC 15 probes. Safety assess-
ments included recording the probing depth (PD = gin-
gival margin to base of sulcus) and recession (REC =
cemento-enamel junction [CEJ] to gingival margin) at
the mid-facial of the canines. Measurements were made
to the nearest 1.0 mm. The clinical attachment level
(CAL) was taken as the sum of the probing sulcus
depth and the recession.
15
A positive REC measure-
ment indicated exposure of the CEJ. In addition, a sin-
gle measurement of PD and REC was obtained on the
facial/buccal aspect of any tooth showing recession
as determined by a visible CEJ. After the rst set of
canine probings, the examiner assessed all teeth for
visible buccal recession, and the PD and REC were
determined for these teeth. After the assessment of all
buccal/facial surfaces with visible recession, the exam-
iner repeated the canine probings so that dual mea-
surements of PD and REC were obtained at the mid-
facial surface of the 4 canine teeth. None of the teeth
included in either assessment had crowns or large
restorations. In one subject, a canine was missing and
the measurements were made on the adjacent lateral
incisor. Intra-examiner reliability for the PD and REC
measurements were shown to be high, and these analy-
ses will be reported in detail in a subsequent paper.
After the safety assessment was completed, the sub-
jects proceeded to a second station where a single
examiner recorded calculus and stain indices.
Calculus and stain assessment. The Volpe-Man-
hold calculus index
16
and the Claydon stain index
17
were carried out essentially as described with the
exception that canine teeth were not included in either
assessment. A single examiner trained in their use and
who showed strong reproducibility during calibration
sessions prior to the start of the study made all mea-
surements. Calculus was assessed on the lingual sur-
faces of the mandibular incisors using the UNC probe
and subsequently analyzed as mean value per tooth.
Color and intensity of dental stain was determined on
the facial surfaces of the maxillary and mandibular
incisors, and when these measurements were com-
pleted the subjects were sent to have MGI and crevic-
ular uid assessments.
Measures of inflammation and plaque. Gingival
crevicular uid (GCF) was used as an initial measure
of inammation on a randomly selected subpopula-
tion of patients (n = 126). Time constraints prevented
all subjects from providing GCF samples. Samples
were collected from posterior interproximal sites using
a standard method.
18
Briey, a single examiner iso-
lated and dried the areas to be sampled and inserted
paper strips

into the sulcus until gentle resistance

was felt. GCF was collected for 30 seconds from the
mesials of non-restored rst molars or nearest non-
restored teeth. The fluid volume measurement was
obtained using an electronic impedence device

using
an equation derived from the calibration data. The 4
sites were averaged to give a GCF value per patient.
This index was carried out prior to the MGI.
Two calibrated examiners then assessed full mouth
gingival inflammation using the modified gingival
index.
14
Facial/lingual marginal tissue and interprox-
imal papillae were scored on a scale of 0 to 3 as
described and full-mouth mean values were calculated.
The interexaminer standard deviation for repeated mea-
sures was 0.12 MGI units. The third and nal inam-
mation assessment was carried out after all plaque
assessments, and this consisted of dual examiners
recording the percentage of sites which bled upon gen-
tle manual probing (BOP) with a UNC-15 periodontal
probe. Efforts were made to have the same examiner
stay with the same patient throughout the study. Using
a dichotomous index (bleeding present/absent), 6 sites
per tooth were assessed 30 seconds after probing.
772
Crest, Procter & Gamble, Cincinnati, OH.
Periopaper gingival uid collection strips, ProFlow, Inc., Amityville, NY.
Periotron 8000, Pro Flow, Inc.
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J Periodontol July 2002 Dentino, Derderian, Wolf, et al.
The Turesky modication of the plaque index
19
was
recorded after the MGI assessment, and subjects were
disclosed using 4 drops of a disclosing solution, swish-
ing for 30 seconds, and rinsing twice with water. Two
calibrated examiners made all the measurements and
the interexaminer standard deviation for repeated mea-
sures was 0.14 PI units. Teeth with crowns or large
restorations were not included in the assessments.
Overnight plaque (7 to 12 hours) was assessed at both
the baseline and 3-month visits. At the 6-month visit,
subjects again reported to the clinic with overnight
plaque. However, before plaque disclosure and assess-
ment the subjects were asked to use their assigned
brush with toothpaste until they felt their teeth were
clean as they normally would do at home. This was
done out of sight of the examiners in a room equipped
with a sink, mirror, and a clock with a second hand
directly above the mirror. The subjects were timed
without their knowledge to get some idea of compli-
ance. The Turesky plaque index was carried out imme-
diately post-brushing. No personalized oral hygiene
instruction was given at any point in the study.
Statistical Analysis, Sample Size, and Power
An ANOVA was used to compare baseline means for
the 2 treatment groups for PI, CI, and stain color and
intensity, as well as to compare calculus formation at
3 and 6 months. Immediate post-brushing 2-month
plaque index was analyzed by ANCOVA using brush-
ing time as a covariate. Correlations of plaque index
with brushing time from the 6-month visit were carried
out over the entire population and by treatment (pow-
ered or manual brush). t tests were used to assess sta-
tistical signicance of the mean values for all indices
over time within both treatment groups. All measures
of inflammation (GCF, MGI, and %BOP), as well as
staining, plaque, and probing assessments (PD, REC,
and CAL) were analyzed by ANOVA as the change
from baseline to account for small differences in the
initial treatment group means. Changes in gingival
margin position were also analyzed in a subset of
patients who showed recession on non-canine teeth at
baseline (PB = 30, M = 28). The average millimeter
amount of recession on the non-canine teeth was com-
pared over 6 months for both groups.
The study was sized to have an 80% chance of detect-
ing a of 0.19 plaque index units between the power
and manual brush 3-month change from baseline PI
means if, in fact, that difference exists. The sample size
calculations used = 0.05 for a 2-sided test of hypothe-
ses. The standard deviation used in the sample size
calculations, = 0.40 plaque index units, was taken
from historical studies using the same PI. The power
analysis shows the smallest difference that would be
detectable 80% of the time if a difference exists between
treatment means for each response variable (Table 2).
RESULTS
One hundred fty-seven subjects completed the trial
(76 in the powered brush group and 81 in the manual
group). Based on the observation that all brushes/
brush heads returned at the 3- and 6-month visits
showed some amount of bristle splaying, it appeared
that all subjects had used the assigned brush.
The baseline means for PI, CI, and stain color and
intensity were not signicantly different between groups
at baseline (Table 3). The values recorded indicate
that the population as a whole had moderate overnight
plaque levels, mild calculus accumulation, and very lit-
tle stain. Probing assessments indicated that of the
157 subjects, 58 (37%) presented at baseline with at
least one vestibular site of visible recession as deter-
mined by exposure of the CEJ. In the PB group there
were 130 non-canine sites in 30 subjects with reces-
sion at baseline, while the M group had 134 non-canine
sites in 28 subjects (Table 4).
Safety Assessment
No subjects reported difculty in using their assigned
brush and there were no significant adverse effects
related to toothbrush use by patient report or by oral
exam. Canines were chosen for repeated PD and REC
measures and all buccal/facial surfaces with recession
were also assessed since these areas may be at risk
for recession.
20,21
The mean values for PD, REC, and
CAL at baseline and 6 months are shown in Table 4.
The ANOVA showed no statistically signicant differ-
773
Table 2.
Power Analysis Showing the Smallest
Difference Detectable 80% of the Time if
a Difference Exists Between Treatment
Means for Each Variable
Standard Detectable
Variable Deviation Difference Power
Plaque index CFB* 0.41 0.190 >0.80
Stain intensity 0.22 0.105 >0.80
Stain color 0.36 0.165 >0.80
Calculus index 0.99 0.455 >0.80
Gingival index CFB 0.32 0.150 >0.80
Molar GCF CFB 0.40 0.185 >0.80
BOP CFB 9.49 4.50 >0.80
Probing depth CFB 0.38 0.175 >0.80
Recession CFB 0.15 0.070 >0.80
*Change from baseline.
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Powered Versus Manual Toothbrushing Volume 73 Number 7
774
ence in these measurements over time between treat-
ment groups.
Data from individuals who showed non-canine teeth
with recession at baseline were further examined. The
amount of recession (mm) per site was averaged for
each patient and the change over time was compared.
In this evaluation, both groups showed a slight decrease
in recession from baseline to 6 months within groups,
but the changes from baseline means were not signif-
icantly different between groups (Table 4).
Measures of Inammation
All baseline measures of inflammation were similar
between the powered and manual groups (Table 3),
and they suggest that the population as a whole did
enter the trial with gingivitis. As expected, the 3 dif-
ferent measures of inflammation went down signifi-
cantly after the baseline prophylaxis as recorded at the
3-month visit and this carried over to the 6-month visit
even in the absence of ossing (Table 3 and Fig. 2A,
B, and C). All 3 independent measures followed the
same pattern for both brushes, and although the change
from baseline in full mouth % BOP and posterior inter-
proximal GCF from the PB group remained greater at
the 6-month assessment compared to the manual
group, the differences were not statistically signicant
between treatments.
Plaque, Calculus, and Stain
The efcacy of mechanical plaque removal was mea-
sured as change in overnight plaque (PI) frombaseline
to 3 months, or as immediate post-brushing of overnight
plaque (6 months). Initially, we were interested in
recording the amount of reduction seen in overnight
plaque after subjects had 3 months to get used to using
their assigned brush. At 3 months the mean whole-
mouth overnight plaque scores showed a decrease for
both brushes when compared to baseline. However,
there was a greater reduction in the full-mouth plaque
levels of the powered brush users (0.29) when com-
pared to the manual brushers (0.13), and this difference
was statistically signicant between the brushes as mea-
sured by ANOVA (P = 0.027) (Fig. 3A). Table 5 shows
the breakdown of overnight plaque in anterior, poste-
rior, and lingual sites and indicates that the powered
brush was more effective in reducing all 3 areas in com-
parison to the manual brush. Statisti-
cally signicant differences were seen
in the anterior and lingual areas, but not
in the posterior.
Subjects returned at the 6-month
assessment with overnight plaque accu-
mulation (7 to 12 hours). After calculus,
stain, GCF, and MGI assessments, the
subjects brushed their teeth, using their
assigned brush, away from the exam-
iners. Plaque was then disclosed and
the Turesky MPI recorded immediately
after brushing. The brushing time was
assessed without the subjects knowl-
Table 3.
Summary of the Mean Values (SD) for
Plaque, Calculus, and Stain Efcacy
Measures
Powered Manual
(N = 76) (N = 81) P Value
Plaque index
Baseline 1.86 (0.50) 1.93 (0.47) NS
3 months 1.57 (0.46) 1.80 (0.40) 0.0013
6 months 1.10 (0.35) 1.39 (0.36) 0.0025
Stain intensity
Baseline 0.259 (0.34) 0.266 (0.33) NS
3 months 0.09 (0.19) 0.12 (0.22) NS
6 months 0.109 (0.21) 0.174 (0.23) NS
Stain color
Baseline 0.358 (0.44) 0.358 (0.42) NS
3 months 0.145 (0.27) 0.186 (0.32) NS
6 months 0.176 (0.34) 0.286 (0.37) NS
Calculus index
Baseline 1.64 (1.25) 1.47 (1.34) NS
3 months 0.549 (0.83) 0.852 (0.90) 0.0304
6 months 0.906 (0.92) 1.33 (1.05) 0.0078
Gingival index
Baseline 1.36 (0.37) 1.38 (0.37) NS
3 months 0.49 (0.25) 0.59 (0.26) NS
6 months 0.52 (0.22) 0.58 (0.23) NS
Molar GCF (l)
Baseline 0.68 (0.33) 0.54 (0.30) NS
3 months 0.47 (0.47) 0.39 (0.24) NS
6 months 0.47 (0.35) 0.44 (0.23) NS
% BOP
Baseline 24.2 (11.5) 25.1 (12.4) NS
3 months 15.8 (11.6) 16.8 (9.2) NS
6 months 13.4 (9.2) 15.5 (9.5) NS
Table 4.
Summary of the Mean (SD) Probing Measurements
Between-
Powered Manual Group
Baseline 6 Months Baseline 6 Months P Value
Canine (N = 76) (N = 81)
PD 1.65 (0.44) 1.75 (0.34) 1.66 (0.45) 1.68 (0.40) NS
REC 0.17 (0.40) 0.14 (0.37) 0.15 (0.45) 0.15 (0.38) NS
CAL 1.24 (0.72) 1.33 (0.63) 1.20 (0.71) 1.22 (0.68) NS
Non-canine N = 30 N = 28
REC 1.45 (0.51) 1.20 (0.58) 1.63 (0.61) 1.46 (0.50) NS
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J Periodontol July 2002 Dentino, Derderian, Wolf, et al.
775
edge, and the data were used to run a correlation
analysis on whole mouth mean plaque index and
brushing time.
Immediate post-brushing plaque levels were clearly
lower for the powered brush (PB = 1.09, M = 1.39)
(Fig. 3B; Table 3), and the time spent brushing was
also signicantly longer (PB = 125 sec, M = 84 sec; P
= 0.0157). An ANCOVA was carried out to compare
the 6-month plaque levels using brushing time as the
covariate. When brushing time is accounted for, the
difference in plaque levels was still signicantly lower
for the PB (P = 0.0025).
Both brushes showed a weak negative correlation
with brushing time (PB = 0.0524, M = 0.2868), which
became stronger when the data were pooled (r =
0.37696) (Fig. 4). A single subject from the PB group
was dropped for the correlation analysis since he was
clearly an outlier in terms of brushing time (270 sec-
onds). Taking all other subjects together the negative
correlation (0.377) indicates that as brushing time
increased, plaque levels were reduced (Fig. 4). The
range of brushing times was large, from 28 to 270
seconds. However, 50 out of 76 powered brush users
spent at least 2 minutes. In contrast, only 14 out of 81
manual brushers spent 2 minutes or more brushing.
Stain and calculus recorded at baseline indicated
similar values between the 2 treatment groups at base-
Figure 2.
Change in gingival inammation. A. Whole-mouth mean MGI. B. Whole-
mouth mean % bleeding on probing (PB, n = 76; M, n = 81 for MGI
and BOP). C. Posterior interproximal gingival crevicular uid ow (PB,
n = 57; M, n = 69). P values reect within group changes from
baseline to 3 and 6 months. *PB, P = 0.009; M, P = 0.0003 (0-3
months.

PB, P = 0.008; M, P = 0.024 (0-6 months).

Figure 3.
A. Change in overnight plaque index from baseline to 3 months. The
difference in treatment means is statistically signicant, with the
powered brush showing a greater change than the manual brush. B.
Six-month immediate post-brushing plaque index is signicantly lower
for the PB after adjusting for brushing time as a covariate.
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776
line (Table 3). However, since a complete prophylaxis
was carried out at the end of the baseline visit, each
subject began the brushing treatments with no visible
stain or calculus. Therefore, an ANOVA was carried
out on the mean values at 3 and 6 months, which
reect calculus and stain formation over time.
The stain levels in this population were low in both
color and intensity before the baseline prophylaxis.
Moreover, both groups showed a signicant number
of subjects with no visible stain at baseline. At base-
line these values were essentially identical between
the 2 groups and, although the values at 3 and 6
months numerically favored the PB users, there was
no statistically signicant difference in staining between
groups. There were, however, signicant differences
between treatment groups in calculus levels at 3 and
6 months as measured by ANOVA (P = 0.0304, 3
months; P = 0.0078, 6 months) (Fig. 5). This nding
is consistent with the signicantly better plaque reduc-
tion in the lower lingual incisor surfaces seen with the
PB (Table 5).
DISCUSSION
The objective of this study was to assess the safety
and efcacy of an oscillating-rotating powered tooth-
brush in comparison to a manual brush over 6
months use in a population with no previous experi-
ence using a powered brush and no formal oral
hygiene instruction. Many studies support the con-
cept that powered toothbrushing can provide addi-
tional clinical benet in plaque removal and inam-
mation reduction when subjects receive proper
instruction and training on the use of the brushes
under study.
2,9,11
Fewer studies have examined pow-
ered versus manual brushing in the absence of oral
hygiene instruction, but the data in this area suggest
written oral hygiene instructions are insufcient for
obtaining maximum improvement in plaque removal.
8
The data from this 6-month trial suggest that the
oscillating rotating powered brush can provide sta-
tistically signicant and arguably clinically relevant
differences in plaque reduction and calculus forma-
tion in the lower lingual anterior surfaces. Previous
work by Isaacs and coworkers shows a similar result
with regard to decreased calculus levels in PB users
compared to manual brush users in a 6-week cross-
over study.
22
These ndings may be due in part to
differences in brush head design, with the smaller,
circular brush head of the PB gaining better access
to difcult to reach areas. They may also reect bet-
ter compliance on the part of the PB users who had
the advantage of an automatic 2-minute timer. Our
brushing time data support this idea, and previous
studies have suggested that powered toothbrush use
is benecial for compliance with oral hygiene.
23,24
It
is interesting to note that when subjects were asked
to brush their teeth until they thought they were clean,
Figure 4.
Correlation of brushing time to 6-month immediate post-brushing
plaque index. Overall negative correlation suggests that as brushing
duration increases plaque levels are reduced.
Figure 5.
Calculus formation as measured by the Volpe-Manhold index.
16
As
shown, calculus formation is lower for the powered brush group at both
the 3- and 6-month visits. Lower levels are statistically signicant.
Table 5.
Overnight Plaque Index Change From
Baseline to 3 Months by Area
PB (N = 76) M (N = 81) PValue
Whole mouth 0.29 (0.49) 0.13 (0.41) 0.0270
Anterior teeth 0.39 (0.60) 0.13 (0.47) 0.0031
Posterior teeth 0.21 (0.53) 0.09 (0.45) NS
Lingual surfaces 0.28 (0.47) 0.11 (0.38) 0.0157
Lower incisor 0.58 (1.1) 0.21(0.68) 0.0112
lingual surfaces
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777
as they normally did at home, the manual brush users
had shorter brushing times. Far fewer manual brush
users spent a full 2 minutes brushing, even though
they knew they were going to have their plaque lev-
els assessed. We believe this underscores the advan-
tage of a timing device. As expected there was a
negative correlation between plaque index and brush-
ing time for all subjects; however, the smaller devi-
ation in brushing times for the PB group (PB, SD =
23.8 seconds; M, SD = 31.4 seconds), as well as the
likelihood of a lower total plaque level based on the
3-month PI data, may account for the weaker nega-
tive correlation between brushing time and plaque
index seen in the powered brush users.
Our observations on plaque reduction are consistent
with van der Weijden and coworkers who examined
plaque and inammation reduction in a non-dental
gingivitis population at several time points and noted
signicantly more plaque reduction in the oscillating-
rotating brush users as compared to manual brush-
ers.
9
In contrast to our ndings, they demonstrated a
signicant between-group difference in inammation
and not simply a signicant reduction over time. These
differences may be related to study design including
methods of measurement, levels of inammation at
the outset of the studies, and level of oral hygiene
instruction during the trial. Similar to the present pro-
tocol, subjects were encouraged to brush for 2 min-
utes twice a day, plaque and calculus were assessed
using the same indices, and a prophylaxis was given
early in the study. Unlike the present protocol, van der
Weijdens manual group was given a timing device
and both groups were given professional oral hygiene
instruction at 1, 2, and 5 months after baseline. It is
not clear if patients were allowed to oss. The Ams-
terdam population had slightly lower plaque levels but
higher gingival indices at baseline than the subjects in
the present study. A more recent 12-month study also
compared the oscillating-rotating brush to a manual
brush providing data consistent with our ndings.
11
The protocol was similar to the present study in that
non-dental patients were investigated and a prophylaxis
was carried out at baseline. Although oral hygiene
instruction was given at the start of that study, it was
not repeated at the 3-, 6-, or 12-month evaluations.
Ainamo and coworkers found that the oscillating-rotat-
ing brush was superior to the manual brush in remov-
ing plaque in the anterior lingual areas. Using a con-
stant force probe they also found that by 6 months
subjects using the powered brush showed signicantly
less BOP when compared to manual brush users. Both
treatment groups saw a signicant reduction in BOP
from baseline to 3 months, which is likely related to
the prophylaxis, the initial oral hygiene instruction, and
the Hawthorne effect.
While the present data on inammation reduction
failed to detect signicant or clinically relevant differ-
ences between the 2 brushes over the 6-month period,
the changes from baseline were signicant for both treat-
ments. We did not observe any signicant differences
in stain color or intensity within or between brushes.
This latter observation is in contrast to previous stud-
ies,
25,26
but this is likely the result of differences in study
design and power. The subjects in our population did
not use any stain-enhancing rinses, and they started
the study with wide variability in staining; many subjects
had little or no measurable stain upon entering the study,
which limited the usefulness of this assessment.
Historically, improper toothbrush use has been asso-
ciated with gingival recession.
13,27,28
Since recession
is observed frequently on teeth that are prominent in
the dental arch,
20,21
we decided to assess all canines
as well as teeth with buccal/facial recession at base-
line. We felt that monitoring the probing depth, reces-
sion, and clinical attachment levels in these areas
would be clinically relevant since these areas could be
at risk for additional recession and clinical attachment
loss. Teeth with crowns were excluded to avoid the
plaque-retentive articial interface. The observations
in this study expand on the previous comparative stud-
ies by examining the issue of safety in a more detailed
way. There are very few studies that have compara-
tively assessed recession in long-term powered and
manual toothbrush use.
29,30
Moreover, these studies
looked at recession over time in a very limited con-
text. The present study, however, looked rather closely
at sites predisposed to recession and found no signif-
icant changes between groups in recession or attach-
ment loss in these areas. Although there were statis-
tically significant within-group differences over time
for mean PD in the PB group and for REC in both non-
canine groups (P values not shown), the clinical rele-
vance is questionable since the precision and power
of our measurements were not at a level to detect
changes in the tenth of a millimeter range (Tables 2
and 4). The observation that both brushes showed a
similar pattern suggests that the powered brush is as
safe to use as a manual brush on sites that have exist-
ing recession or may be predisposed to recession
based on their prominence in the dental arch. Over-
all, no clinically relevant change in mean sulcus depth,
recession, or attachment level occurred on the facial
surfaces of canines in either group over 6 months.
The data presented in this paper strongly suggest
that the oscillating-rotating powered brush can be used
safely without formal instruction. In addition, the pow-
ered brush can provide additional clinical benet over
a manual brush in terms of plaque and calculus levels.
It is likely that the higher efcacy of the powered brush
is related to the smaller head design as well as to the
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Powered Versus Manual Toothbrushing Volume 73 Number 7
778
presence of a timing device to encourage longer brush-
ing times. This study clearly does not suggest that oral
hygiene instruction is without merit; rather, based on
previous ndings, one might expect even greater ben-
ets if subjects were instructed on proper oral hygiene.
ACKNOWLEDGMENTS
This study was funded by Braun/Oral B, Kronberg,
Germany and statistical analysis carried out by StatKing
Consulting, Cincinnati, Ohio. MaryAnn Cugini is the
manager of Clinical Research and Dental Affairs, and
Paul Warren is the vice president of Clinical Research
and Dental Affairs at Braun/Oral B. Dennis King and
Pam Marks are statisticians at StatKing Consulting.
The authors dedicate this work to the memory of
Randy Johnson, a superb teacher, clinician, and friend
who passed away on October 3, 2001.
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Correspondence: Dr. Andrew Dentino, Marquette University
School of Dentistry, P.O. Box 1881, Milwaukee, WI 53201-
1881. E-mail: andrew.dentino@marquette.edu.
Accepted for publication February 15, 2002.
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