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ORIGINAL ARTICLE
Year : 2017  |  Volume : 21  |  Issue : 2  |  Page : 138-143  

“Is powered toothbrush better than manual toothbrush in removing dental plaque?” – A crossover randomized double-blind study among differently abled, India


Department of Public Health Dentistry, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeswara University, Mysore, Karnataka, India

Date of Submission13-Aug-2017
Date of Acceptance08-Sep-2017
Date of Web Publication29-Dec-2017

Correspondence Address:
Byalakere Rudraiah Chandrashekar
#8, Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_185_17

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   Abstract 

Background: Although mechanical plaque removal is an effective method, powered toothbrushes are specially designed to benefit differently abled. Literature comparing plaque removal efficacy between manual and powered toothbrushes among differently abled is sparse. Study Design and Setting: A cross-over, randomized, double-blind study was conducted in differently abled institution. Materials and Methods: Twenty differently abled participants were randomly assigned to two groups of ten participants. Plaque removal efficacy of battery-operated powered toothbrush was compared with manual toothbrush in a single brushing on the 8th day. After a washout of 1 week, groups were switched. Assessment of plaque scores was done using Turesky's modification of Quigley-Hein plaque index. Statistical Analysis: Difference in plaque score between pre- and post-brushing in each group was compared using paired sample t-test. Results: In the pooled data analysis combining the results of Phase I and II, mean pre- and post-brushing plaque scores with manual toothbrush was 2.26 ± 0.4 and 1.93 ± 0.5, respectively, while with powered toothbrush, it was 2.21 ± 0.4 and 1.96 ± 0.4, respectively. However, difference in mean plaque reduction between manual and powered toothbrushes was not significant. Conclusion: Manual toothbrushes were equally effective compared to powered toothbrushes. Long-term studies precisely documenting cost-effectiveness and participant perception in the ease of use are recommended to validate our results.

Keywords: Dental plaque, dental plaque index, disabled, powered and manual toothbrush, randomized controlled trial


How to cite this article:
Neelima M, Chandrashekar BR, Goel S, Sushma R, Srilatha Y. “Is powered toothbrush better than manual toothbrush in removing dental plaque?” – A crossover randomized double-blind study among differently abled, India. J Indian Soc Periodontol 2017;21:138-43

How to cite this URL:
Neelima M, Chandrashekar BR, Goel S, Sushma R, Srilatha Y. “Is powered toothbrush better than manual toothbrush in removing dental plaque?” – A crossover randomized double-blind study among differently abled, India. J Indian Soc Periodontol [serial online] 2017 [cited 2021 Sep 19];21:138-43. Available from: https://www.jisponline.com/text.asp?2017/21/2/138/220458


   Introduction Top


Among various oral diseases, dental caries and periodontal diseases are the most common. They are multifactorial, but most common etiology is specific species of the microorganisms present in supra- and sub-gingival plaque.[1] Hence, removal of plaque is one means to prevent disease as it brings about a change in habitat of the oral cavity.

Established methods of plaque removal include different mechanical and chemical processes. By far, mechanical plaque removal remains the common way to control plaque. Manual toothbrush is the most common vehicle used in mechanical method. At present, different types of toothbrushes are available. Although plaque removal by mechanical method is important for prevention and maintenance of periodontal disease, majority of the population do not brush in a proper manner, which results in poor oral health status of the individuals.[2]

In the 1960s, electric toothbrush was introduced by Dr. Philippe Guy Woog. The ease of use was cited as a potential advantage of powered toothbrush over manual toothbrush especially among differently abled population who may lack manual dexterity required for optimum oral hygiene maintenance.[3] Poor oral hygiene among differently abled population may be due to their functional limitations and limited access to undergo oral examination.[4]

A significant number of studies have been done comparing plaque removing efficacy of manual and powered toothbrushes.[3],[4] Literature comparing the plaque-removing efficacy between manual and powered toothbrushes has given contradictory results with few studies claiming superiority of powered toothbrushes over manual toothbrushes.[1],[5],[6],[7] While few studies found no such difference.[2]

Moreover, published literature comparing plaque-removing efficacy of manual and powered toothbrushes among the differently abled adults is sparse. Hence, the present study was undertaken with the hypothesis – “Is Powered toothbrush better than Manual toothbrush in removing dental plaque?” among differently abled in Mysore City.


   Materials And Methods Top


This was a double-blind, crossover, randomized controlled trial conducted in an institution for differently abled in Mysore city, India. Study was conducted in accordance with Declaration of Helsinki. Ethical clearance for the study was obtained from Institutional Ethical Committee (IEC). Before the start of the study, permission from the head of the differently abled institution was obtained. Study was conducted over a period of 1 month from December 2016 to January 2017.

Training and calibration

Training and calibration of principal investigator involved in data collection were undertaken at Department of Public Health Dentistry. Turesky's Modification of Quigley-Hein plaque index was discussed with subject experts to clarify ambiguity related to scoring before the calibration procedure was undertaken. Calibration was done on ten participants.

Participants were allotted in a random manner when examination procedures were undertaken. Allotment of participants was done by faculty, and assessment was done in their supervision. Clinical oral examination was done using sterile instruments under adequate illumination. Cronbach's alpha for intraexaminer reliability was 0.78.

Sample size

This study was undertaken on twenty differently abled participants selected from a school. Sample size estimation was done using nMaster software for hypothesis testing for two means (equal variances). Assuming a mean difference of 0.3 between the two methods, for an effect size of 1.2 at 5% α error and 80% power, sample size was computed to be 9 per group. The sample size was rounded off to 10 anticipating 10% drop out. Total sample size turned out to be 20 in view of crossover design.

Selection of study participants

After obtaining permission from the head of the differently abled institute, individuals were screened initially. Individuals and their respective care taker and in-charge staff were explained about study procedures and confidentiality of their participation. Individuals who were willing to participate and satisfied eligibility criteria were included in the study. Participants who could brush on their own (mentally undisturbed, assessed by participant's medical record available in institution office) were included while those with orthodontic appliances and implants were excluded. Twenty participants were recruited after initial screening. Informed consent was obtained before the start of the study. These twenty participants were randomly allocated into two groups through computer-generated random allocation sequence. Each participant in Group I were given an oral hygiene kit coded I, while participants in Group II were given an oral hygiene kit coded II in Phase I of the study. Group allocation and distribution of coded oral hygiene kit were done by coordinator who was not involved in data collection. Investigator collecting data on dental plaque was blinded. Each participant received coded oral hygiene kit consisting of manual/powered toothbrush and toothpaste.

Participants who received the manual toothbrushes were instructed to follow their routine practice while those receiving powered toothbrush followed manufacturer's instructions. Study schedule was handed out to all concerned care takers. On the 8th day following distribution of oral hygiene kits, staff in-charge reminded participants on returning their coded oral hygiene kit. Before their oral hygiene kits were collected back, plaque status was assessed before and after brushing. Participants were requested to refrain from oral hygiene practices for 6 h on the scheduled day of assessment (8th day). Plaque disclosing agent was dispensed into disposable plastic cups. Participants were instructed to swish the agent for 1 min and then expectorate into same disposable cup. Then, he/she was sent into examination hall where the principal investigator clinically examined these participants. Plaque scores were assessed using Turesky-Gilmore-Glickman modification of the Quigley-Hein Plaque Index by the investigator. Then, participant was allowed to brush for 3 min. Staining and scoring of postbrushing plaque scores were done as described earlier. Allotment of participant for clinical examination in both pre- and post-brushing was done by the coordinator in a random order to ensure blinding of the investigator.

A washout period of 1 week was allowed where the participants followed their routine practice they had before the start of study. After 1 week, the groups were switched. Participants in Group I received oral hygiene kits coded II, while participants in Group II received kits coded I. Assessment of plaque status was done on the 8th day following the distribution of oral hygiene kits using the method described in Phase I of the study. No changes were made in the research protocol after the commencement of the study, and final analysis was done after completing Phase II of the study with no interim analysis.

The CONSORT flow diagram of the study is presented in [Figure 1].
Figure 1: CONSORT flow diagram of the study; n: number of participants

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Statistical analysis

Statistical analysis was done using SPSS version 22 (IBM, Chicago, IL, USA). The difference in plaque score between the groups at baseline and postbrushing in each phase was compared using independent sample t-test. The difference in plaque score between pre- and post-brushing in each group was compared using paired sample t-test. Statistical significance was fixed at 0.05. Pooled data analysis combining the recordings in the first and second phase was done at end. Statistician was blinded about group allocation as the entire analysis was done using the group codes.


   Results Top


The present study was undertaken to assess the plaque removal efficacy of manual and powered toothbrushes among twenty differently abled in Mysore city, India. All participants completed the study with no dropouts. Among twenty participants, sixteen were males while remaining four were females. The mean age of the study participants was 16.1 ± 2.3 years. There was no significant difference in the mean age of the study participants [P = 0.1].

Mean plaque reduction on single brushing assessed using Modified Quigley-Hein Plaque Index in Phase I

Overall, mean pre- and post-brushing plaque scores were 2.26 ± 0.4 and 2.04 ± 0.4, respectively. Mean pre- and post-brushing plaque scores with manual toothbrush were 2.41 ± 0.3 and 2.15 ± 0.3, respectively, while with powered toothbrush, it was 2.11 ± 0.4 and 1.92 ± 0.4, respectively. There was a significant reduction in the mean plaque score postbrushing compared to prebrushing values with both manual (P = 0.03) and powered toothbrushes (P = 0.008). Mean reduction in plaque score at postbrushing compared to prebrushing was 0.27 ± 0.4 and 0.19 ± 0.2, respectively, for manual and powered toothbrushes. However, there was no significant difference in mean plaque reduction between manual and powered toothbrushes [P = 0.97, [Table 1].
Table 1: Mean plaque reduction on single brushing assessed using Modified Quigley-Hein Plaque Index in Phase I

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Mean plaque reduction on single brushing assessed using Modified Quigley-Hein Plaque Index in Phase II

Mean pre- and post-brushing plaque scores were 2.20 ± 0.5 and 1.86 ± 0.5, respectively. Mean pre- and post-brushing plaque scores with manual toothbrush were 2.31 ± 0.5 and 2.00 ± 0.4, respectively, while with powered toothbrush, it was 2.10 ± 0.5 and 1.71 ± 0.5, respectively. There was a significant reduction in the mean plaque score postbrushing compared to prebrushing values with both manual (P = 0.02) and powered toothbrushes (P = 0.005). Mean plaque reduction scores at postbrushing compared to prebrushing for manual and powered toothbrushes were 0.31 ± 0.3 and 0.39 ± 0.3, respectively, with no significant difference between manual and powered toothbrushes [P = 0.19, [Table 2].
Table 2: Mean plaque reduction on single brushing assessed using Modified Quigley-Hein Plaque Index in Phase II

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Mean plaque reduction on single brushing assessed using Modified Quigley - Hein Plaque Index pooling data in Phase I and II

Mean pre-and post-brushing plaque scores were 2.23 ± 0.4 and 1.95 ± 0.4, respectively. Mean pre- and post-brushing plaque scores with manual toothbrush were 2.26 ± 0.4 and 1.93 ± 0.5, respectively, while with powered toothbrush, it was 2.21 ± 0.4 and 1.96 ± 0.4, respectively. There was a significant reduction in mean plaque score postbrushing compared to prebrushing values with both manual (P< 0.001) and powered toothbrushes (P< 0.001). However, there was no significant difference in mean plaque reduction between manual and powered toothbrushes [P = 0.24, [Table 3]. None of the participants expressed any difficulty in the use of assigned oral hygiene kits and no adverse effects were reported.
Table 3: Mean plaque reduction on single brushing assessed using Modified Quigley-Hein Plaque Index pooling data in Phase I and II

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   Discussion Top


The prevalence of differently abled varies from country to country, but it was estimated that they constitute approximately 500 million. According to National Sample Survey Organization, it was estimated that 1.8% of population were disabled in the country.[8] Literature suggests that these people have poorer general and oral health in comparison with general population. This was attributed to their restricted activity and limited access to health care and oral health has always been neglected.[4] Major thrust for introduction of powered toothbrush was to improve ease of use among differently abled population with limited dexterity.[9] Various short- and long-term studies that assessed pre- and post-brushing plaque reduction among general population without any physical or mental disabilities using manual and powered toothbrushes found mixed results. Few studies claim superiority of powered toothbrushes over manual toothbrushes while others claim no such difference.[1],[2],[5],[6],[7] Vibhute and Vandana in their systematic review found no significant difference between powered and manual toothbrushes.[10] Yaacob et al. in a systematic review comparing manual and powered toothbrushes found powered toothbrushes to be more effective in reducing plaque and gingivitis compared to manual toothbrushes.[11]

However, studies comparing efficacy of these powered toothbrushes with manual brushes among disabled population are sparse.[12],[13] In view of this, the present study was undertaken to compare plaque removal efficacy of powered and manual toothbrush among differently abled in Mysore city.

In the present study, we found no significant difference in mean plaque reduction between manual and powered toothbrushes in both Phase I (P = 0.9) and Phase II (P = 0.19). The pooled data analysis combining the results of Phase I and II also found no significant difference in mean plaque reduction between manual and powered toothbrushes (P = 0.24). This clearly indicates that even the manual toothbrushes were equally effective compared to powered toothbrushes which have been specifically developed to enhance efficacy of plaque control among individuals lacking manual dexterity. These results were similar to the findings of a study by Goyal et al., who also found no significant difference in mean plaque scores among brushes in mentally challenged children (P > 0.05).[13] Parizi et al. in their study also found manual toothbrushes to be equally effective in comparison with powered toothbrushes similar to our results.[2] Postbrushing mean plaque scores in the present study, with manual and powered toothbrush, were 1.93 ± 0.5 and 1.96 ± 0.4, respectively. These scores were slightly higher (postbrushing manual = 0.62 ± 0.03, postbrushing powered = 0.93 ± 0.03) in comparison with study conducted by Williams et al.[5] Our results were contradictory to the findings of studies who found plaque reduction to be more with powered toothbrushes.[1],[5],[6],[7] The contradiction could be attributed to difference in study participants, study design, and methods employed to measure plaque scores. In the present study, we assessed the efficacy of plaque reduction by manual and powered toothbrushes in a single brushing. In the light of no significant differences between manual and powered toothbrushes, it is worthwhile to undertake more such studies among population with different levels of disabilities. This will enable us to understand and comment on cost-effectiveness of powered toothbrushes. However, powered toothbrushes will always be a choice when patients require assisted brushing such as those severely diseased and disabled. Compliance was found to be good with no adverse consequences reported in the present study. High compliance could be due to “novelty effect.”[13] However, “Hawthorne effect” affecting the outcome cannot be ruled out despite allowing washout period of 1 week.

Differences in types and designs of manual toothbrushes, powered toothbrushes used, differing study designs, study population, parameters included to assess efficacy of toothbrushes, methods used to assess plaque scores, patterns of oral hygiene practices followed, and various other reasons mark the limitation of comparing available evidence-based literature.

Strengths

The present study assessed plaque removal efficacy of different types of toothbrushes among differently abled.

Limitations

Psychosocial aspects and participant's perceptions on ease of using different types of toothbrushes were not taken into consideration. Although type of disability was noted, we could not precisely assess their degree of disability. With smaller sample size, we could not undertake any subgroup analysis based on severity of disability.

Cost factor

Cost of one battery-operated powered toothbrush was around Rs. 400/-, while one manual toothbrush was costing Rs. 40/-. Manual toothbrush was one tenth the cost of powered toothbrush questioning the economic viability of powered toothbrushes over manual toothbrushes.

Recommendations

In view of limitations cited earlier, we recommend further long-term multicenter trials with different types and severity of disabilities on large population base that enable subgroup analysis. These long-term studies can validate our results with regard to

  1. Plaque-reducing efficacies of powered and manual toothbrushes
  2. Cost-effectiveness between powered and manual toothbrushes
  3. Psychosocial aspects and participants' perceptions on ease of using powered and manual toothbrushes
  4. Creating awareness among differently abled, their parents, and caregivers with specific indications for powered toothbrushes where they will be most cost-effective rather than advising them for all differently abled having minor disabilities.



   Conclusion Top


Based on the findings in the present study, we conclude that there was no significant difference in plaque-removing efficacy between powered and manual toothbrushes among differently abled in a single brushing although we found significant reduction postbrushing compared to prebrushing values for both these brush types.

Acknowledgement

I acknowledge Mr. Siddesh, the distributor; Principal of differently abled institution and the participants for their cooperation. I am thankful to Dr. Jai Shankar, Department of Oral Medicine and Radiology for his extended support. I express my deep sense of gratitude to Mr. Mohd Neyas Mohd Sali, Miss Nikita Francis, Mr. Jinith PV, Mr. Manzoor, Mr. Ashik Mohan, and Miss Rekha Girijan.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Haffajee AD, Thompson M, Torresyap G, Guerrero D, Socransky SS. Efficacy of manual and powered toothbrushes (I). Effect on clinical parameters. J Clin Periodontol 2001;28:937-46.  Back to cited text no. 1
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2.
Parizi MT, Mohammadi TM, Afshar SK, Hajizamani A, Tayebi M. Efficacy of an electric toothbrush on plaque control compared to two manual toothbrushes. Int Dent J 2011;61:131-5.  Back to cited text no. 2
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3.
Deacon SA, Glenny AM, Deery C, Robinson PG, Heanue M, Walmsley AD, et al. Different powered toothbrushes for plaque control and gingival health. Aust Dent J 2011;56:231-3.  Back to cited text no. 3
    
4.
Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents. J Indian Soc Pedod Prev Dent 2009;27:151-7.  Back to cited text no. 4
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Williams K, Ferrante A, Dockter K, Haun J, Biesbrock AR, Bartizek RD, et al. One- and 3-minute plaque removal by a battery-powered versus a manual toothbrush. J Periodontol 2004;75:1107-13.  Back to cited text no. 5
    
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Terézhalmy GT, Bartizek RD, Biesbrock AR. Relative plaque removal of three toothbrushes in a nine-period crossover study. J Periodontol 2005;76:2230-5.  Back to cited text no. 6
    
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Dentino AR, Derderian G, Wolf M, Cugini M, Johnson R, Van Swol RL, et al. Six-month comparison of powered versus manual toothbrushing for safety and efficacy in the absence of professional instruction in mechanical plaque control. J Periodontol 2002;73:770-8.  Back to cited text no. 7
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Available from: http://www.mospi.gov.in/national-samplesurvey-office-nsso. [Last accessed on 2017 Apr 13].  Back to cited text no. 8
    
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Harris NO, Godoy FG, Nathe CN, editors. In: Primary Preventive Dentistry. 8th ed. Philadelphia: Pearson Education; 2014. p. 134-44.  Back to cited text no. 9
    
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Vibhute A, Vandana KL. The effectiveness of manual versus powered toothbrushes for plaque removal and gingival health: A meta-analysis. J Indian Soc Periodontol 2012;16:156-60.  Back to cited text no. 10
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Yaacob M, Worthington HV, Deacon SA, Deery C, Walmsley AD, Robinson PG, et al. Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev 2014;17:CD002281.  Back to cited text no. 11
    
12.
Doǧan MC, Alaçam A, Aşici N, Odabaş M, Seydaoǧlu G. Clinical evaluation of the plaque-removing ability of three different toothbrushes in a mentally disabled group. Acta Odontol Scand 2004;62:350-4.  Back to cited text no. 12
    
13.
Goyal S, Thomas BS, Bhat KM, Bhat GS. Manual toothbrushing reinforced with audiovisual instruction versus powered toothbrushing among institutionalized mentally challenged subjects – A randomized cross-over clinical trial. Med Oral Patol Oral Cir Bucal 2011;16:e359-64.  Back to cited text no. 13
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