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Using an Evidence-based Approach to Making Patient Recommendations for Power Toothbrushes

Course Number: 648

Plaque and Gingivitis Control

One reason first generation electric toothbrushes were not widely promoted beyond special needs and orthodontic populations in the 1960s and 1970s was a lack of evidence that they provided equivalent or superior plaque control to a standard manual toothbrush. Keep in mind, O-R and sonic power brushes were not launched until the late 1980s-early 1990s. It was during the 1998 European Workshop on Mechanical Plaque Control, Dr. G.A. van der Weijden, (ACTA, Amsterdam), concluded, It was reported during the 1998 European Workshop on Mechanical Plaque Control that using electric toothbrushes appear to be superior to using manual brushes.26

With new power toothbrush models debuting frequently, dental professionals may wonder how to best assess the effectiveness and safety of them since all brushes do not perform equally well. Ideally, toothbrush claims should be supported by well-controlled clinical research. The following table provides a summary of research findings related to plaque and gingivitis control comparing different electric technologies and manual toothbrushes. The RCTs represent individual studies whereas, the Systematic Review represent multiple studies on the same topic.

Table 4. Summary of Research Studies (RCTs & Systematic Review) on Plaque and Gingivitis.

Source/Study Author
Year & Reference
# Studies/SubjectsOutcome/Conclusions Summary
Robinson PG et al. Cochrane Systematic Review; Power vs. manual brush, 2005.642 Studies; Included a total of 4,000 subjectsOnly power toothbrushes which employed a rotation-oscillation action were proven consistently superior at removing plaque and reducing gingivitis more effectively than manual brushes in the short and long-term.
Biesbrock AR et al. (P&G); RCT; oscillating-rotating vs. sonic toothbrush; plaque removal efficacy and safety, 2008.2745 SubjectsBoth brushes were found to be safe and significantly reduced plaque after a single brushing. Oral-B Triumph was significantly more effective in plaque removal than Sonicare (P < 0.0001). Compared to Sonicare FlexCare, the adjusted mean plaque reduction scores for Oral-B Triumph were 21%, 23% and 22% greater for whole mouth, marginal and interproximal areas, respectively.
Deacon SA et al. Cochrane, Systematic Review of Different Powered TBs for Plaque & Gingivitis, 2010.2817 Studies; Included 1369 subjects, 4 weeks up to 3 months; 7 trials up to 3 months at leastSome evidence that rotation-oscillation power toothbrushes reduced plaque and gingivitis more than side-to-side (sonic) power brushes in the short-term. The difference is small, and its clinical importance is unclear.
Klukowska M, et al. (P&G); RCT; Oscillating-rotating toothbrush vs. standard manual brush 2010.29118 subjects;
4 weeks
O-R electric toothbrush yielded significantly superior reductions in gingivitis (by almost 3x) and bleeding and plaque (by almost 2x) compared to manual brush.
Yaacob M, et al. Cochrane Systematic Review; Power vs. manual brush, 2014.1356 studies; Included 4,624 subjectsPower toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term. O-R technology was the only power brush consistently shown to reduce more plaque and gingivitis vs. manual brushing in the short and long term. There was no significant difference between manual brushes and side-to-side (sonic brushes) in the reduction of plaque or gingivitis.
Klukowska M, et al. (P&G); RCT; Oscillating-rotating toothbrush vs. a new sonic brush, 2014.30130 Subjects (127 completed); 12 weeksO-R toothbrush demonstrated statistically significantly greater reductions in whole mouth plaque at Weeks 6 and 12, and significantly greater gingivitis reductions over the long-term (12 weeks), compared to the new sonic toothbrush.
Starke M et al. (Sonicare); RCT; Sonic vs. O-R on gingival health & plaque status with subjects with moderate gingivitis, 2017.32284 subjects;
6 weeks
A new sonic toothbrush was statistically superior to an older model O-R-P toothbrush in reducing gingival inflammation, gingival bleeding, and supragingival plaque following 2 and 6 weeks of home use.
Ccahuana-Vasquez RA et al. (P&G); RCT; O-R vs. Sonic in reducing gingivitis & plaque in those with pre-existing gingivitis and plaque, 2018.31150 Subjects;
8 weeks
Both brushes reduced MGI, GBI, total number of bleeding sites, whole mouth plaque, gingival margin plaque, and proximal plaque (p < 0.001 for each). The O-R brush provided statistically significantly greater reductions than the sonic brush for all gingivitis measures, including # of bleeding sites after eight weeks of use (p < 0.001). Significantly greater whole mouth (26.2%) and proximal (38.5%) plaque reductions were also demonstrated at Week 8 for the O-R brush versus the sonic brush (p < 0.001).
Goyal CR et al. RCT; Comparison of Waterpik Sonic-Fusion with a traditional sonic and manual toothbrush and flossing, 2018.12105 Subjects;
4 weeks
WaterPik Sonic-Fusion was significantly more effective than a traditional sonic toothbrush or a manual toothbrush and flossing for reducing gingival bleeding and inflammation.
Wang P et al. Systematic Review with MA; Comparison of the effectiveness between power toothbrushes and manual toothbrushes for oral health, 2019.3321 Studies; Included 2,296 subjectsPower toothbrushes are more effective in reducing dental plaque, gingivitis and bleeding compared to a manual toothbrush.
Mirza F et al. (Sonicare); RCT; Comparison of 2 power toothbrushes on gingival inflammation and supragingival plaque, 2019.34222 enrolled, 219 subjects completed; 6 weeksSonicare DiamondClean Smart powered toothbrush reduced gingival inflammation more significantly than the Oral-B Genius 8000 powered toothbrush. Both were safe for use.
Grender J et al. (P&G); Systematic Review with MA; on plaque & gingival health; studies conducted by P&G from 2007-2017; 2020.3516 Studies; Included 2,145 subjects for gingival health; & 20 Studies, Included 2,551 subjects for plaque reduction; up to 3 monthsGingivitis assessed via number of bleeding sites and standardized changes in average plaque scores. Both O-R and sonic technology reduce bleeding sites and plaque scores better than a manual brush, however using New AAP/EFP Gingivitis Classifications, O-R provides 7.4x significantly greater odds of patients transitioning from gingivitis to generally healthy state (<10% bleeding sites).67
Grender J et al. (P&G); RCT; Comparison of New Oral-B iO O-R brush with micro-vibrations and manual brush for gingivitis and plaque reduction with subjects with plaque & gingivitis, 2020.36110 subjects;
8 weeks
Using New AAP/EFP guidelines, O-R electric toothbrush with micro-vibrations provided statistically significantly greater plaque and gingivitis reductions versus a manual toothbrush. Odds of transitioning from not healthy (≥10% bleeding sites) at baseline to ‘healthy’ (<10%) gingivitis status at week 8 was 14.5x higher than using the ADA manual brush.
Adam R et al. (P&G); RCT; New Oral-B iO O-R brush with microvibrations and premium sonic brush, 2020.3790 subjects;
8 weeks
Using New AAP/EFP guidelines, O-R electric toothbrush with micro-vibrations provided statistically significantly greater plaque and gingivitis reductions than the sonic toothbrush. After 8 weeks 84% of subjects moved to healthy state with novel OR brush versus 53% with the sonic brush.
Lyle DM et al. (WaterPik); RCT; Water flosser + O-R power toothbrush, 2020.2570 subjects;
4 weeks
Oral hygiene regimen of a water flosser + O-R powered toothbrush significantly improved gingival health as compared to an O-R powered toothbrush alone.
Clark-Perry D et al. Systematic Review with MA; O-R & other power TBs, 2020.3815 Studies; Included 1,968 subjectsO-R toothbrushes had superior, statistically significant outcomes for whole-mouth plaque reduction, (P < .01), and gingivitis, assessed by using number of bleeding sites (P < .001), but not for the modified gingival index (P > .05) or gingival bleeding index (P > .05). O-R brush might remove more plaque and reduce the # of bleeding sites better than other power toothbrushes.
Elkerbout TA et al. Comparison of a powered toothbrush with a manual toothbrush, 2020.7117 StudiesThere is moderate certainty that the Power TB was more effective than the Manual TB with respect to plaque removal following a single brushing exercise independent of the plaque index scale that was used.
Grender J,et al. The effects of oscillating-rotating electric toothbrushes on plaque and gingival health: A meta-analysis, 2020.6816 RCTs; 2,145 subjects for gingivitis;
20 RCTs 2,551 subjects for plaque
This subject-level meta-analysis of studies up to 3 months provides sound evidence supporting recommendations for patients with various degrees of gingival bleeding to use oscillating-rotating electric toothbrushes over manual and sonic toothbrushes to improve plaque control and gingival health.
Thomassen TJA, et al. The efficacy of powered toothbrushes: A systematic review and network meta‐analysis, 20226928 publicationsThere is a high certainty for a small effect of a PTB over an MTB. This supports the recommendation to use a powered toothbrush for daily plaque removal. There is moderate certainty for a very small benefit for the use of a powered toothbrush with an Oscillating-rotating (OR) over an High-Frequency Sonic (HFS) mode of action.
Sager P, et al. Powered tooth brushes are beneficial for long-term oral health: Results from the Study of Health in Pomerania (SHIP-TREND), 2023702214 participantsA recommendation of PTB usage in dental practice could contribute to the long-term promotion of oral health.
Graves A, et al. Systematic Review and Meta Analysis of the Relative Effect on Plaque Index among Pediatric Patients Using Powered (Electric) versus Manual Toothbrushes, 2023.7138 studies, 1,626 orthodontic and non-orthodontic pediatric subjectsThese results provide strong clinical evidence for recommending electric toothbrushing to pediatric patients, as well as those patients undergoing orthodontic therapy and treatment.
Zou Y, et al. A Meta-analysis Comparing Toothbrush Technologies on Gingivitis and Plaque. 2023.7221 Gingivitis RCTs, 25 Plaque RCTsOscillating-rotating toothbrushes offer superior results for transition to health, gingivitis, and plaque reduction compared with manual and sonic brushes. The most advanced oscillating-rotating model (iO) offers enhanced efficacy vs traditional models.

Overall, research findings demonstrate that the O-R and sonic brushes (side to side) are significantly more effective in reducing plaque and gingivitis than a manual toothbrush; and, the majority of RCTs and Systematic Reviews with a Meta-analysis report the O-R technology is more effective than sonic technology. Additionally, the most advanced O-R models offer enhanced efficacy versus traditional O-R models.72