General health and well-being are conditions that include having a good oral health. According to the World Health Organization, oral health is “a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial well-being.” The most common oral diseases are dental caries, periodontal disease, and oral cancer.

As stated by the World Health Organization, 60-90% of school children and about 100% of adults have dental caries. Both dental caries and periodontal diseases are caused by plaque and can be prevented by having a proper oral hygiene with adequate brushing and flossing technique and the use of fluoride. Extensive evidence has shown that mechanical plaque removal is the most efficient method of preventing dental caries and periodontal disease. Since the cariogenic process starts with the retention of plaque, eliminating plaque will prevent the colonization of bacteria from occurring and will act as a preventative method. Therefore, if the patient is able to remove the plaque with appropriate brushing, he will be doing the main step for caries prevention. Lamentably, having a successful mechanical technique for plaque control is not easy, considering that requires time and dexterity, many individuals advise that it is monotonous and difficult to master.The purpose of this paper is to investigate the efficiency in plaque removal of powered toothbrushes.

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Is, in fact, a powered toothbrush more efficient than manual? Bacterial biofilm is naturally present in the oral cavity and widely known as the main cause of dental caries and periodontal disease. Therefore, mankind tried to keep its teeth clean since remote periods of history. Excavations had found chewing sticks used by Babylonians in 3500 BC but the first device to use bristles was invented in China approximately 1600 DC. The first version of what we know as a toothbrush was recreated in the late 18th and early 19th centuries. Around 1885, a toothbrush was patented by H.N. Wadsworth and began to be produced massively in North America but it was not until 1938 when the natural bristles were replaced by nylon and the soldiers coming back from the World War II brought the Army’s mandatory habit of brushing and introduced it to society (Jardim et al., 2004).

A manual toothbrush can be effective in removing dental plaque when used correctly for the adequate amount of time. However, many people do not brush appropriately due to a lack of patience or physical and mental disability. An alternative to manual toothbrush can be an electric toothbrush. The first electric toothbrush was designed by Dr. Philippe Guy Woog in Switzerland in 1954 aiming to have a solution for patients with decreased motor skills and cognition problems and orthodontic patients besides to help patients with the right brushing technique.  A powered toothbrush was launched in the American market in the 1960s by Squibb under the name Braxodent.

Much technological progress was made regarding the design and bristle motion of the powered toothbrush since its creation.  The manner in which the powered toothbrush acts can be classified as mechanical, sonic and ionic. Mechanical when the head makes oscillating and rotating movements, sonic when the head and bristles rotate and ionic that changes the charge of the tooth, attracting food and plaque off the tooth (Penick, 2004).The brush head of a mechanical toothbrush rotates back and forth at a tremendous speedup of 2,500 – 7,500 cycles per minute on average. This movement is called an oscillation. The mechanical or so-called “rotary” electric toothbrush performs at the frequency of oscillation varies from 40 Hz (cycles per second) for battery-powered brushes to 250 Hz for magnetostrictive devices. In general, their brush heads are small and circular, resulting them easy to move around any areas of the mouth. The brushing motion, back and forth, is similar to a manual toothbrush.

Some models of rotary electric brush exhibit a forward and backward vibration. This action helps the bristles reach further into the interproximal area.Some modern rotary toothbrushes oscillate back and forth at a greater frequency of 8,800 strokes per minute. They additionally perform a pulsating motion that creates movements as high as 40,000 pulses per minute.

This pulsating-rotary toothbrush can produce a “non-contact” cleaning effect as seen in regular sonic toothbrushes. A non-contact brushing is an action of powered brush being able to remove oral biofilm beyond its bristles actually touch, resulting from agitating the fluids that surround the teeth.               The sonic toothbrush uses a side to side vibrating movement at high frequency, creating a scrubbing action of bristles. The effectiveness of this cleansing mechanism is dependent on the amplitude of the brush head (the distance it moves up or down on each stroke) and the frequency (number of strokes per minute). Additionally, the sonic toothbrush produces a secondary effect (as known as the dynamic fluid effect) which is generated by the intense vibrations of the brush head that causes the fluids (water and saliva) flush around the teeth.

The moving liquid generates tiny bubbles and associated hydrodynamic shear forces that remove the dental plaque from a distance of at least 2.65 mm beyond the brush bristle tips (Hope & Wilson, 2003). The ionic toothbrushes work by changing the polarity of the teeth, in other words, it changes temporarily the natural negative charge of the teeth to positive charge, in order to repel the natural charge of the food that is positive.

The coupling between the bacteria and pellicles is derived from calcium bridge formation. The bristles are electrically charged by the battery and pull plaque and food away from the teeth. The anions released from the battery through the bristles’ tips inhibit the mild electrostatic bonding between the bacteria and calcium ions hence it prevents the adherence of bacteria to the pellicles. The effect of ionic exchange added to the normal mechanical action of the bristles on the tooth surface enhances the removal of dental plaque.  Effectiveness of Powered Toothbrushes Several types of powered toothbrushes have different technology and mechanism to effectively clean the teeth or removing dental plaque.

Countless studies comparing the effectiveness in plaque control between manual and powered toothbrushes have revealed various results.A meta-analysis by Yaacob and coworkers (2014) reported the effectiveness of both toothbrushes on oral hygiene. Their review statistically demonstrated that the dental plaque was statistically removed by powered toothbrushes more than manual toothbrushes in both the short (one to three months) and long-term (over three months). The results of meta-analyses of powered toothbrushes presented a reduction of 11% and 21% in the plaque at short and long term, respectively. Furthermore, a decrease in gingivitis of 6% at short-term and of 11% at long-term was found in this study. These numbers might indicate a beneficial impact of using the powered toothbrush for an extended period of time. However, the authors stated that the clinical importance of these ?ndings remains unclear.A report by Yaacob et al.

(2014) was in accordance with a clinical trial by Jain (2013) that exhibited a highly significant reduction of plaque index scores of powered toothbrushes comparing of manual toothbrushes on the 14th and 42nd days. Recent studies (Jager, Rmaile, Darch, & Bikker, 2017; Nightingale et al., 2015) of the toothbrush ef?cacy for plaque removal summarized that powered toothbrushes safely and effectively removed more plaque than standard manual toothbrushes.

These studies supported earlier evidence base that showed a superior ability in reducing plaque and gingivitis by powered toothbrushing compared with manual toothbrushing (Barlow, Zhou, Roberts, & Colgan, 2004; Holt et al., 2007; Kugel & Boghosian, 2002).                Although much evidence suggests the superior efficacy in plaque removal of powered toothbrushes compared with manual toothbrushes, other studies (Costa et al., 2007; Vibhute & Vandana, 2012) reported that there were no differences between powered and manual toothbrushes in terms of removing plaque. These findings were in agreement with an earlier systematic review (Deery et al.

, 2004) and current meta-analysis (Goh & Lim, 2017); conventional and powered brushes were equally effective in reducing plaque and preventing gingivitis. Deery et al. (2004), nevertheless, reported that the powered toothbrushes with a rotation-oscillation motion could dislodge significantly more biofilm as well as significantly decreased gingivitis in both the short and long term. Intending to compare sonic and ionic toothbrushes, Singh, Mehta, Chopra, and Khatri (2011) did a single-blind study, using a split-mouth method, conducted for 45 days on a total of 22 (11 males and 11 females) student volunteers, with age of 17 to 21 years. Plaque, gingival, and bleeding indices were recorded after every 15 days.

They deduced that both toothbrushes were efficient in plaque removal and decreasing gingival inflammation. However, the sonic toothbrushes showed slightly superior results when compared with the ionic. The powered and manual toothbrushes have an ability to effectively remove dental plaque (Nightingale et al.

, 2015). However, the efficacy of plaque removal by a manual toothbrush compared to a powered toothbrush remains controversial in the average population. A recent meta-analysis (Khan, Nishi & Alam, 2017) summarized that powered toothbrushes had better efficiency in removing plaque and diminishing gingivitis than manual toothbrushes for orthodontic patients. It is very interesting to study the impact of powered toothbrushes in disabled and individuals with special needs such as autism, handicapped and visually impaired.               Peri-implant mucositis is described as inflammation of the mucosa around a dental implant.

It is very similar to gingivitis and it is reversible with a well-done biofilm dislodgement. The progression of the disease causes gradual bone loss around the dental implant. Lee et al. (2015) concluded in their research, where they investigated patients with peri-implant mucositis using manual and powered toothbrushes, that patients who used sonic-powered toothbrushes showed a significant decrease in plaque index and sulcus bleeding index in one month? Therefore, sonic-powered may be a useful tool for plaque management in patients with peri-implant mucositis.               The individuals undergoing orthodontic treatment have greater difficulties in maintaining oral hygiene. The presence of fixed appliances, e.g., orthodontic bands, brackets, and wires, facilitates the accumulation of biofilm around them and they become crucial to developing carious lesions and periodontal disease.

The powered toothbrushes have been introduced as an alternative measure to manual toothbrushes regarding plaque removal. The studies of powered toothbrushes in orthodontic patients yielded different results, the effectiveness of plaque control between manual and powered tooth brushing is inconclusive. Sharma et al. (2015) reported that sonic toothbrushes performed a significantly superior reduction in plaque deposit and gingivitis, from baseline to 4 and 8 weeks, compared to rotational and manual orthodontic toothbrushes used by patients under fixed orthodontic treatment. In contrary, a recent study (Saruttichart et al., 2017) found that manual toothbrushes showed better plaque removal than motionless ultrasonic toothbrushes on teeth with fixed orthodontic appliances. A meta-analysis in efficiency of various toothbrushes in orthodontic patients (Khan et al.

, 2017), however, indicated that powered toothbrushes exhibited the best effect on plaque and gingivitis reduction. The authors of this study had mentioned that in a clinical application the orthodontist should make the best choice of a toothbrush according to the circumstances of the patient’s oral status. The evidence-based research showed that the powered toothbrushes are effective in plaque reduction in patients undergoing orthodontic therapy, but their efficacy is equivalent to manual toothbrushes (Costa et al., 2010; Sharma et al.

, 2015; Sharma, Sidana & Tiwari, 2015). In addition, less force was applied during the use of power toothbrushes in comparison to manual brushes (Weijden et al., 2011) and there was no evidence that it caused any injuries to the gums (Sharma, Sidana & Tiwari, 2015; Khan et al., 2017).                A research was conducted by Cui et al.,2017 to evaluate the efficacy of biofilm removal and gingivitis control by powered and manual toothbrushes in a group of 42 visual impaired students between 12 to 16 year old. Students in the test group used powered toothbrushes while students in control group used manual toothbrushes. The research was divided into two stages.

Oral health status was recorded at baseline, two weeks, and four weeks of each stage. Quigley-Hein Plaque Index (Q-H PI) and Loe and Silness Gingival Index (GI) were used. After the comparison between the baseline, two weeks and four weeks scores were done, it was concluded that no significant differences were noted between the two groups regarding Q-H PI and GI at baseline, whereas Q-H PI and GI values of the test group were significantly reduced compared with those of the control group at 2 weeks and 4 weeks. According to Cui et al(2017), a powered toothbrush showed superiorperformance in the biofilm removal and decreasing gingivitis more than manual toothbrushing among visually impaired school children.

                 Autism is a developmental disorder characterized by troubles with social interaction and communication. Autistic individuals can present many forms of repetitive or restricted behavior. An estimated 60%–80% of autistic people have motor signs that include poor muscle tone and coordination, poor motor planning, and toe walking. Thinking about this group with reduced manual dexterity Vajawata et al 2015 conducted a study with forty autistic individuals to compare the efficacy of powered toothbrushes in improving gingival health as compared to manual toothbrushes.                  The elderly population is increasing rapidly in developed nations.

However, age is still a barrier regarding a good oral hygiene since seniors have decreased dexterity, weakness, and dependency of a caregiver. Fjeld et al. (2014) had reported that nursing homes residents present more remaining natural teeth than years before. Nevertheless, these remaining teeth exhibit root exposure in addition to in numerous dental work. Such as bridges and crowns, restorations, partial dentures, and implants.

Another point to emphasize is that the senior population has diminished muscular strength, xerostomia and restricted physical capacity which impair them to perform an efficient oral cleanliness. All these factors contribute to making the elderly population fragile against plaque attack. Targeting the nursing homes population, Fjeld et al. (2014) conducted a single-blinded, randomized controlled clinical trial to investigate the e?ect of electric toothbrushes (ET) compared with manual toothbrushes (MT), and evaluated the caregiver’s opinion on ET. A sample of 180 nursing-home residents was given either a new ET or a new MT.

The study concluded that with a new device and controlled routine, oral hygiene was enhanced. Comparing the effects of ET and MT was found no difference between them. However, the ET seems to be a useful dental tool for residents who need assistance with oral hygiene. As caregivers also evaluated ET to be bene?cial, more nursing-home residents should be assisted with ET during dental hygiene.

The evidence-based studies of powered toothbrushes were generally performed in the short term (one to three months) and long-term (three to six months) whereas the significant improvement in plaque removal in the short term possibly relates to a transitional Hawthorne effect. Having a new toothbrush might add a motivation of brushing so that a better initial plaque removal resulted. Therefore, a longer term of observation, i.e., up to two years, would be beneficial and of value to the public.

Several advantages of powered toothbrushes over manuals are documented in many studies (Costa et al., 2007; Khan et al., 2017; Nathoo, Mankodi & Mateo, 2012; Sharma et al.

, 2015; Sharma, Sidana & Tiwari, 2015). They are convenient to use, required with minimal effort, able to reach a difficult-to-access area in the mouth, and less forceful to the tooth structure on average. Moreover, no evidence of gingival trauma was reported (Weijden et al., 2011) so that they are considered safe to use on a daily basis.  The powered toothbrush, therefore, has been suggested to be beneficial for certain populations that have increased the difficulty in maintaining oral hygiene including impaired manual dexterity, mentally challenged and elderly. They also can be recommended for children and younger patients to have an enjoyable experience.Currently, there are numerous commercial powered toothbrushes with distinctive designs and unique features on the market.

This is of a concern to populations especially those may require greater supervision while brushing to ensure the proper technique is being used. Dental hygienists have a significant role to educate the patients and caregivers on choosing an appropriate toothbrush and using it with proper technique to promote their oral hygiene in the long term. ConclusionAccording to Goh and Lin (2017), powered toothbrushes are as effective as manual toothbrushes in facilitating oral hygiene by detaching plaque and decreasing gingivitis. They are safe and no signs of harm in soft and hard tissues were found. Studies suggested that rotation-oscillating toothbrushes may be more effective than others.

               Results have been reported that the use of powered toothbrushes may benefit the individuals with special needs such as elderly and disabled patients. They may be recommended for particular patient groups, who are unable or unwilling to properly use a manual toothbrush, to develop a better oral hygiene condition. In addition, the introduction of powered brushing probably helps motivate the average person to brush their teeth with greater efficiency.

Whether a manual or powered toothbrush is recommended for a given patient, instructions on the use of the toothbrush, and oral hygiene are mandatory.


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