5906Silverman

Pediatric Dentistry – 26:3, 2004 Silverman et al. 225Comparison of powered and manual toothbrushes

Scientific Article

ince the introduction of the electric toothbrush, many

articles have been published evaluating its effective-

ness in adults, persons with disabilities, and children

undergoing orthodontics.

1-3

However, there has been lim-

ited research performed with healthy children. When

Heasman and McCracken

published an extensive review

of electric toothbrush studies in 1999, only 3 of the stud-

ies were conducted on healthy children. Ritsert and Binns

and Grossman and Proskin

found that an electric tooth-

brush was more effective in removing plaque than a manual

toothbrush when used by children and adolescents. How-

ever, Crawford

found no significant difference in plaque

and gingival scores when electric and manual toothbrushes

were compared in well-motivated 9- to 15-year-olds.

The standard brushing time used in child and adult stud-

ies is 2 minutes.

6,8-10

Some studies have extended that time

to 3 minutes.

11,12

MacGregor and Rugg-Gunn,

however,

reported that the average time spent brushing by unsuper-

vised 13-year-olds was only 1 minute. In another study, they

reported that unsupervised 5-year-old children spent an av-

erage of 58 seconds brushing, with only 5% of that time

spent on brushing the lingual surfaces of their dentition.

Kotch et al

conducted a study comparing the

Oralgiene 60 Second Time Machine powered toothbrush

to another powered toothbrush, as well as to a manual

toothbrush. The Oralgiene toothbrush was shown to be

more effective in removing plaque, especially on palatal and

interproximal surfaces. The study was conducted only on

adults and allowed the participants to brush as long as they

liked. In their marketing, Oralgiene claims that only 60

seconds are needed to brush properly. The company be-

gan marketing a smaller brush head for their toothbrush

that is meant to be used by children under 6 years of age

and only for 60 seconds.

Comparison of Powered and Manual Toothbrushes for

Plaque Removal by 4- to 5-year-old Children

Joseph Silverman, DMD, MBA R. Glenn Rosivack, DMD, MS

Pamela B. Matheson, MA, PhD Milton I. Houpt, DDS, PhD

Dr. Silverman is a former postdoctoral student, Dr. Rosivack is clinical professor, and Dr. Houpt is professor and chair, Department of Pediatric

Dentistry, Dr. Matheson is associate dean for Planning and Assessment, New Jersey Dental School, Newark, NJ.

Correspond with Dr. Silverman at [email protected]

Abstract

Purpose: This study compared the small head Oralgiene 60 Second Time Machine pow-

ered toothbrush, used for 60 seconds, with the Braun Oral-B Mickey Mouse powered

toothbrush and a manual toothbrush (Oral-B Rugrats 20), each used for 2 minutes, for

efficacy in plaque removal and reduction of gingival inflammation in young children.

Methods: Fifty-eight children, ages 4 to 5 years old, were randomly assigned to one of the

3 toothbrush groups. At visit 1, plaque and gingival indices were recorded for all subjects.

Then, the children did not brush for 24 hours. At visit 2, 24 hours later, plaque indices

were recorded, the children brushed with their assigned toothbrush, and plaque indices

were recorded again. Six weeks later, plaque and gingival indices were recorded again. The

data was analyzed to detect plaque reduction after a one-time use (visit 2, prebrushing and

postbrushing) as well as plaque and gingival inflammation reduction after 6 weeks of use.

Results: The Oralgiene toothbrush removed significantly more plaque during the one-

time trial and reduced significantly more gingival inflammation during the 6-week trial.

The Braun Oral B powered toothbrush removed significantly more plaque than the other

toothbrushes during the 6-week trial. However, no clinically meaningful differences were

found between any of the toothbrushes with regard to plaque removal or gingival scores.

Conclusions: There were no clinically meaningful differences found between any of the

toothbrushes tested during either of the trials with regard to plaque removal or improve-

ment in gingival health. (Pediatr Dent. 2004;26:225-230)

EYWORDS: POWERED TOOTHBRUSH, MANUAL TOOTHBRUSH,

PLAQUE REMOVAL, PEDIATRIC DENTISTRY

Received November 1, 2002 Revision Accepted January 1, 2004

226 Silverman et al. Pediatric Dentistry – 26:3, 2004Comparison of powered and manual toothbrushes

Many previous studies in

children have focused on

plaque removal, however,

Hugoson

found that 64%

of 5-year-olds have gingivi-

tis on 1 or more tooth

surfaces. Therefore, it is also important to assess gingival

health when evaluating toothbrushes used by this age group.

The purpose of this study was to compare the small head

Oralgiene powered toothbrush, used for 60 seconds, with

another electric toothbrush (Braun Oral-B Mickey Mouse)

and a manual toothbrush (Oral-B Rugrats 20), each used

for 2 minutes, for efficacy in plaque removal and gingivi-

tis reduction in children under 6 years of age.

Methods

This study was approved by the University of Medicine and

Dentistry of New Jersey Institutional Review Board. All

toothbrushes used in the study were supplied by Oralgiene

USA, Inc. Oralgiene was provided with a copy of the study

results, however, the company was not involved in the data

collection or interpretation of the results.

A 3-group, 3-treatment, single-blinded clinical trial was

performed on 60 children, 4 to 5 years old. Written informed

consent was obtained from the parents or legal guardians of

all children involved in the study. The subjects were chil-

dren who attended the Moriah School in Englewood, NJ.

The principal investigator and one of the co-investigators

performed the clinical aspects of the trial at the school. All

examinations, instructions, and toothbrushing took place in

the school nurse’s office with the use of a portable dental chair

and light. Exclusion criteria included a history of periodon-

tal disease, mental handicap, physical handicap that restricts

free movement of the hands, acute intraoral lesions, or the

need for subacute bacterial endocarditis prophylaxis prior to

dental treatment.

At baseline, an examination of the oral soft tissues and

dentition was performed. Plaque was scored using the

Turesky modification of the Quigley and Hein index (PI)

(Table 1). Gingival inflammation was scored using the

Gingival Index (GI)

(Table 2). All PI and GI measure-

ments were performed by the same investigator. GI was

recorded at 6 sites around all of the teeth (mesiobuccal,

midbuccal, distobuccal, mesiopalatal, midpalatal,

distopalatal). PI values were recorded for the facial and lin-

gual surfaces of all the teeth following use of a disclosing

agent applied with a cotton applicator. Plaque and gingi-

val indices were performed on all teeth which were present

at the time of the examination. This included fully erupted

primary teeth as well as partially erupted permanent teeth,

as this is the typical dentition of 4- and 5-year-old children.

Using a random numbers table, each subject was randomly

assigned to 1 of 3 treatment groups according to the tooth-

brush to be used during the study. The 3 toothbrushes were:

1. Oralgiene 60 Second Time Machine powered tooth-

brush (Figure 1);

2. Braun Oral-B Mickey Mouse powered toothbrush

(Figure 2);

3. Oral-B Rugrats 20 manual toothbrush.

The technical specifications for each toothbrush are

shown in Table 3. The subjects were told to use their regu-

lar toothpaste during the length of the study. The type of

toothpaste used at home was determined from the origi-

nal questionnaire and was distributed evenly among the

treatment groups. After the baseline visit, the subjects were

asked to refrain from tooth cleaning for the next 24 hours.

At visit 2, 24 hours later, the plaque indices were recorded

again and the appropriate toothbrushes were given to each

subject. Instructions on the use of the powered and manual

*Turesky et al.

0 No plaque

1 Separate flecks of plaque at the cervical margin

2 A thin band of plaque at the cervical margin

3 A band of plaque wider than 1 mm but covering

less than one third of the crown

4 Plaque covering at least one third but less than

two thirds of the crown

5 Plaque covering more than two thirds of the crown

Table 1. Plaque Index Scores*

*Loe.

0 Normal gingiva

1 Mild inflammation, no bleeding on probing

2 Moderate inflammation, bleeding on probing

3 Severe inflammation, tendency to spontaneous bleeding

Table 2. Gingival Index Scores*

Figure 2. The Braun Oral-B

Mickey Mouse powered

toothbrush head.

Figure 1. The Oralgiene 60

Second Time Machine

powered toothbrush head.

Pediatric Dentistry – 26:3, 2004 Silverman et al. 227Comparison of powered and manual toothbrushes

toothbrushes were given by the principal investigator with

the use of a pediatric dental typodont. The time for brush-

ing was 1 minute for the Oralgiene powered brush and 2

minutes for the Braun Oral-B Mickey Mouse electric tooth-

brush and Oral-B Rugrats 20 manual toothbrush. The

powered toothbrushes each had built-in timers and the

manual toothbrushes were distributed with egg timers. The

subjects were then asked to brush their own teeth, under

supervision, to check compliance with the technique. The

assignment of toothbrushes and brushing were performed

without the presence of the examining investigator. The

plaque indices were then recorded again.

The subjects were asked to use their allocated tooth-

brushes at home for the next 5 to 7 weeks, brushing 2 times

a day: morning and before bed. At visit 3, 6 weeks later,

the examination was repeated and plaque and gingival in-

dices recorded. The examinations at visits 1 and 3 were

undertaken within 3 to 5 hours after the subjects had

cleaned their teeth. At the end of visit 3, each subject had

completed the trial.

Analysis of data

Sample size estimation was con-

ducted to determine the

necessary group sizes in order to

assure detection of significant

differences should they occur

(alpha=0.05, power ≥0.8). Us-

ing the variability data associated

with plaque index in the sample

evaluated by Kotch et al

and es-

timating a medium effect size (Cohen’s convention=0.32),

it was determined that the minimum number of cases re-

quired was 51 participants, with 17 in each treatment group.

Prior to the study, an intrarater reliability test was per-

formed using 6 subjects. Gingival indices were scored by

the examiner. Each subject was then rescored in a differ-

ent order by the same examiner. The same procedure was

used for scoring the plaque indices following the use of a

disclosing agent. Agreement was 93% for the gingival in-

dex; however, there was a problem with the attempt to

evaluate intrarater reliability with the plaque index. Since

the disclosing agent fades between measurement intervals,

the outcome being measured changed, resulting in an in-

ability to assess intrarater reliability with the disclosing

agent. Given the excellent intrarater reliability with the

gingival index, it was assumed that the observer would be

internally consistent in his measurements across all study

parameters.

Oralgiene 60 Second

Time Machine electric Oral B Mickey Mouse Oral B Rugrats 20

Toothbrush toothbrush (compact) electric toothbrush manual toothbrush

Number of tufts 52 21 (16 white and 5 blue) 23

Filaments per tuft 80 White=48Blue=68 20

Total number of filaments 4,160 1,108 460

Number of rows White=1Blue=3 N/A 3

Weight 6.8 oz 4.3 oz 0.3 oz

Handle length 180 mm 130 mm 105 mm

Handle circumference 135 mm 90 mm 30 mm

Head size 20 mm diameter 12.4 mm diameter 9.5x 24 mm

White=8.3–8.8 mm White=6 mm

Filament length Blue=3.2±0.3 mm Blue=7 mm 9.5±0.8 mm

Compressive load needed to activate 3.3 pounds 2.3 pounds N/A

Oscillation frequency 360-410/min 5,600/min N/A

Oscillation angle 72˚ 50˚ N/A

Filament material Nylon Nylon Nylon

Angle of bristles 45˚ 90˚ 90˚

Bristle ends Flat Round Round

Table 3. Comparison of Toothbrush Specifications

Assigned N baseline N 6-week Gingival index Gingival index

toothbrush and visit 2 follow-up at baseline at 6-week follow-up

Manual 20 20 0.14±0.11 0.11±0.11

Oral B 19 18 0.11±0.09 0.05±0.05

Oralgiene 20 20 0.13±0.1 0.06±0.06

Table 4. Comparison of Gingival Indices Among Assigned Toothbrushes

228 Silverman et al. Pediatric Dentistry – 26:3, 2004Comparison of powered and manual toothbrushes

An analysis of variance (ANOVA) test at the 0.05 level of

significance for independent groups was performed for baseline

(visit 1) and visit 2 prebrushing findings to detect any

preintervention differences which may have occurred despite

random assignment to treatment groups. Generalized linear

models were used to conduct analyses of covariance

(ANCOVA) to control for any pretest differences if found.

Two separate split plot ANOVAs—one to compare

baseline to visit 3 and one to compare visit 2 prebrushing

and postbrushing—were conducted for each outcome vari-

able (plaque and gingival indices). The first was a 2×3

ANOVA of time (visit 2 prebrushing and postbrushing)

and treatment (toothbrush type: Oralgiene powered, Braun

Oral B powered, or Oral-B manual toothbrush). The sec-

ond was a 2×3 ANOVA of time and treatment, where the

first level of time was baseline taken at visit 1 and the sec-

ond level was measurements taken at visit 3, 6 weeks later.

If scores between the treatment groups were different at

baseline or visit 2 prebrushing, the second analysis used

baseline or visit 2 prebrushing as a covariate when the 6-

week observations among the 3 groups were compared.

Results

There were 60 subjects that participated at the beginning

of the study. One subject dropped out after the first visit

and was, therefore, not included in the results of this study.

Another subject was unable to be present at the final phase

of the study and was, hence, only included in a portion of

the results. All plaque and gingival indices were performed

on primary and erupting permanent teeth.

The whole-mouth mean gingival scores for each tooth-

brush type for each visit of the study are displayed in

Table 4. There was a statistically significant interaction

between the toothbrush type and changes in gingival score

from baseline to the 6-week follow-up visit (P=.0001). The

Oralgiene toothbrush resulted in a larger reduction in gin-

gival score when compared to the manual and the Braun

Oral B toothbrushes (

×=0.07, 0.03, and 0.06, respectively).

Since this study may have suffered from a “basement ef-

fect” because the GI was so low at baseline, no clinically

meaningful decreases in gingival scores could be detected.

The whole-mouth mean plaque scores for each tooth-

brush type for each visit of the study are shown in Table 5.

An ANCOVA analysis was conducted to control for visit 2

prebrushing differences while examining postbrushing

plaque scores. The whole mouth plaque scores were signifi-

cantly different at visit 2 postbrushing. Post hoc analysis via

Scheffe showed that the whole-mouth adjusted mean plaque

scores at visit 2 postbrushing for Oralgiene were significantly

lower than those of the manual and Braun Oral B tooth-

brushes (P<.0001 and P=.028, respectively). Based on

baseline plaque findings, a difference of 0.5 for PI was arbi-

trarily chosen as being clinically meaningful. Consequently,

these observed differences in plaque reduction were not clini-

cally meaningful.

An evaluation was also performed to see if there were

any differences among toothbrushes when individual tooth

surfaces were examined. The mean plaque scores at all 3

visits for facial surfaces are shown in Table 6. An ANOVA

determined that all toothbrush types had significant reduc-

tion between visit 2 prebrushing and postbrushing facial

surface plaque. However, no toothbrush type decreased

facial plaque significantly (P=.990) more than the others.

Plaque index Plaque index Plaque index

Assigned

N baseline N 6-week Plaque index at visit 2: at visit 2: at 6-week

toothbrush and visit 2 follow-up at baseline prebrushing postbrushing follow-up

Manual facial 402 402 2.9±1.30 3.51±1.14 1.78±1.41 2.37±1.35

Oral B facial 392 369 2.83±1.26 3.38±1.10 1.64±1.23 2.03±1.24

Oralgiene facial 401 401 2.67±1.17 3.38±1.08 1.65±1.19 2.35±1.21

Manual lingual 402 402 1.51±1.12 1.92±1.09 1.11±0.96 1.14±0.98

Oral B lingual 392 369 1.51±1.09 1.75±1.11 0.93±0.83 1.02±0.88

Oralgiene lingual 401 397 1.45±1.12 1.72±1.17 0.63±0.73 1.11±0.99

Table 6. Comparison of Facial and Lingual Surface Plaque Indices Among Assigned Toothbrushes

Plaque index Plaque index Plaque index

Assigned

N baseline N 6-week Plaque index at visit 2: at visit 2: at 6-week

toothbrush and visit 2 follow-up at baseline prebrushing postbrushing follow-up

Manual 20 20 2.21±0.55 2.71±0.36 1.44±0.53 1.75±0.53

Oral B 19 18 2.17±0.42 2.56±0.35 1.29±0.32 1.52±0.45

Oralgiene 20 20 2.07±0.43 2.55±0.35 1.14±0.38 1.73±0.5

Table 5. Comparison of Whole Mouth Plaque Indices Among Assigned Toothbrushes

Pediatric Dentistry – 26:3, 2004 Silverman et al. 229Comparison of powered and manual toothbrushes

The mean plaque scores at all 3 visits for lingual sur-

faces are shown in Table 6. An ANCOVA was conducted

to control for pretest differences. The ANCOVA, using

visit 2 prebrushing scores as the covariate, found the lin-

gual plaque scores were significantly different among the

3 toothbrush groups. Post hoc analysis via Scheffe showed

that the lingual adjusted mean plaque scores for Oralgiene

were significantly lower than those of the manual and

Braun Oral B (P<.0001 and P=.040, respectively) at visit

2 postbrushing. This reduction, however, was not clinically

meaningful.

Plaque reduction was also tested over a 6-week trial pe-

riod. An ANCOVA was conducted to control for pretest

differences. Therefore, using an ANCOVA with baseline

whole-mouth plaque scores as the covariate, the whole-

mouth plaque scores at visit 3 were significantly different.

Post hoc analysis via Scheffe showed that the whole-mouth

adjusted mean plaque scores at visit 3 for Braun Oral B were

significantly lower than those of the manual and Oralgiene

(P<.0001). These differences in plaque reduction, however,

were not clinically meaningful.

An ANCOVA was conducted to evaluate facial surface

plaque scores. With the ANCOVA using baseline scores

as the covariate, the facial plaque scores were significantly

different. Post hoc analysis via Scheffe showed that the fa-

cial adjusted mean plaque scores at visit 3 for Braun Oral

B were significantly lower than those of the manual and

Oralgiene (P<.0001). These differences in plaque reduc-

tion, however, were not clinically meaningful.

An ANOVA which evaluated lingual plaque scores deter-

mined that there were no significant differences between

toothbrush type for the amount of lingual plaque reduction

achieved between baseline and the 6-week follow-up (P=.0504).

Tests for compressive load needed to activate the tooth-

brushes were performed using the Enduratec ELF 3200

Series Mechanical Test System with a 50-lb load cell maxi-

mum. Oralgiene was found to have a higher compressive

load than Oral B (3.3 lbs and 2.3 lbs, respectively).

Discussion

The results from the one-time-use trial correspond with

results of previous studies conducted by Savastino,

Lefkowitz and Robinson,

Conroy and Melfi,

Ritsert and

Binns,

Hall and Conroy,

Grossman and Proskin,

and

Jongenelis and Wiedemann.

All these previous studies

showed that the powered toothbrush was more efficient in

removing plaque when compared to a manual toothbrush.

In the present study, however, comparisons were also made

between 2 different powered toothbrushes.

It was found that, in a one-time-use trial, the Oralgiene

60 Second Time Machine toothbrush removed significantly

more plaque than the Braun Oral B Mickey Mouse tooth-

brush. Possible explanations for the greater success of the

Oralgiene toothbrush might be found in the specifications of

each toothbrush. The oscillation frequency of the Oralgiene

is 336 to 410 times per minute as compared to the Braun Oral

B, which is 5,600 times per minute. Oralgiene claims that this

slower rate, which is comparable to the manual toothbrush,

allows the bristles adequate time to straighten and penetrate

between the teeth. The angle of the bristles for the Oralgiene

is 45 degrees, as compared to the Braun Oral B which is 90

degrees. The 45-degree angle allows the bristles to reach un-

der the loose gingiva that covers the cervical portion of the

teeth. Finally, the bristle ends of the Oralgiene are flat while

those of the Braun Oral B are rounded.

After 6 weeks, the results showed that the Braun Oral B

electric toothbrush removed significantly more plaque than

the Oralgiene toothbrush. Possible explanations for this find-

ing are that the Oralgiene toothbrush is manipulated

differently than other powered and manual toothbrushes. On

the day of the one-time-use study, the children were given

instructions on the use of all the toothbrushes. They were

then asked to brush immediately after the instructions were

given. At that point, the children understood how to use the

Oralgiene toothbrush. Later, with no instructional reinforce-

ment, the children may have used the Oralgiene toothbrush

improperly and this may have led to a decrease in the

toothbrush’s efficacy. Another possible explanation may be

found in the specifications of the toothbrushes. The

Oralgiene toothbrush was found to have a larger handle,

weigh more, and take a larger compressive load to activate

the toothbrush. These factors may have contributed to the

children having difficulty in using the toothbrush, which

then could have resulted in less plaque reduction.

The present study also compared the efficacy of the

toothbrushes for plaque removal on the facial and lingual

surfaces. The Oralgiene toothbrush was more efficient in

removing plaque on the lingual surface and the Braun Oral

B toothbrush was more efficient on the facial surface. These

results correspond with those of Kotch et al

who also

found that the Oralgiene brush performed superiorly on

lingual surfaces. A possible explanation for these results may

be that the design of the Oralgiene toothbrush includes

built-in bristles for the lingual surfaces, and these may help

children correctly clean this surface.

In clinical research, “Once differences between groups have

been determined to be statistically significant, there yet remains

the question as to whether those differences are meaningful.

This becomes a rather arbitrary but important interpretation

of the findings with specific reference to the question being

asked.”

Clinicians and patients should not choose a tooth-

brush based on statistically significant differences alone, but

rather on clinically meaningful differences. While Oralgiene

may have performed significantly better in the one-time-use

trial with regard to plaque removal, and Braun Oral B per-

formed significantly better in the 6-week trial for plaque

removal, neither of them were clinically better in either trial.

The fact that the Oralgiene toothbrush was used for only 60

seconds, as compared to 2 minutes for the other 2 tooth-

brushes, becomes an important feature. According to

Honkala,

the duration of brushing affects the amount of

plaque removal. As previously discussed, unsupervised 5-year-

old children brush for approximately 1 minute. Therefore, the

reduced time required for the Oralgiene powered toothbrush

could help address the issue of time-related compliance.

230 Silverman et al. Pediatric Dentistry – 26:3, 2004Comparison of powered and manual toothbrushes

There are a number of issues with powered toothbrushes that

require further research. Authors

25,26

agree that 3- to 5-year-old

children do not have the motor skills to adequately brush their

teeth without supervision. Manufacturers of powered tooth-

brushes are attempting to overcome this manual dexterity

dilemma by improving the design of their brushes, which are

marketed to children. Studies should be conducted to see what

impact design differences have on the efficacy of each tooth-

brush (ie, oscillation frequency, bristle angle, bristle ends, handle

size and weight, and finger pressure needed to activate the unit).

Further understanding of each design feature may enable manu-

facturers to design better toothbrushes in the future.

Since all 3 toothbrushes showed a decrease in plaque scores,

it is unlikely that the type of toothbrush contributed to this

improvement. The plaque reduction could be due to other fac-

tors such as toothbrushing instructions that were given,

awareness by children that they were participating in a study,

or the timer that was given to the children. A repeat of this study

may prove valuable if all 3 toothbrushes are used for the same

amount of time, if the children use their toothbrushes without

instructions from the investigator, or if the children using

manual toothbrushes are not given a timer. If toothbrushing

instructions are found to improve plaque and/or gingival scores

over a 6-week period, it would demonstrate the importance of

performing further studies to evaluate the long-term efficacy of

oral hygiene instructions given to children in the dental office.

Conclusions

There were no clinically meaningful differences found between

any of the toothbrushes tested during either of the trials with

regard to plaque removal or improvement in gingival health.

Acknowledgements

The contribution of all powered and manual toothbrushes by

Oralgiene USA, Inc. is acknowledged with grateful appreciation.

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