Historia Cepillos

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Crest® Oral-B® at dentalcare.com Continuing Education Course, September 6, 2006

Power Toothbrushes: Everything You Need to Know To Make

Informed Recommendations for Your Patients

The information found in this course will arm the dental professional with information and resourcesneeded to make effective power brush recommendations that motivate patients and boost brushingcompliance.

OverviewPower brushes are designed to facilitate the removal of bacterial plaque and food debris from the teethand gingiva and to reduce calculus and stain accumulation.1 The information found in this continuingeducation course will arm the dental professional with information and resources needed to make effective power brush recommendations that motivate patients and boost brushing compliance.

Learning ObjectivesUpon the completion of this course, the dental professional will be able to:• Discuss the history of the power brush.• Compare and contrast the past designs and recommendations of power brushes to the current designs

and recommendations.• Describe the clinical significance of plaque.• Determine the role power toothbrushes play in the removal of plaque.• Discuss research presented on patient compliance with brushing recommendations.• Describe the power brush’s effect on plaque, gingivitis, calculus and stain.• Identify various designs/mechanics of power toothbrushes on the market today.• Discuss the oral safety considerations of power toothbrushes.• Utilize product evidence based research, clinical experience, and patient values to select the best

power toothbrush for each individual patient.• Locate sources of information about dental products.• Utilize science to make recommendations for patients.• Instruct patients on the use of power brushes.

Ginger B. Mann, BSDH, MSContinuing Education Units: 3 hours

at

Continuing Education

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Course Contents• Glossary• History of the Toothbrush• Purpose/Indications of Power Brushes• Designs/Mechanics• Safety• Selection Parameters• Using Science to Make Recommendations• Patient Instruction• Summary• Course Test• References• About the Author

GlossaryAbrasivity — describes a material of various particle size and hardness.

CINAHL — a database for nursing and alliedhealth literature.

Cochrane Collaboration — an organization that aims to help people make well-informed decisions about healthcare by preparing, maintaining andpromoting the accessibility of systematic review of the effects of healthcare interventions.

Dentifrice — another name for a tooth gel, paste or powder.

Editorial boards — a group of people who areexperts in their field who review articles prior to publication.

EMBASE — a database providing rapid access tothe world’s biomedical and drug literature.

Evidence — the data on which a conclusion or judgment may be based; proof.

Gingival abrasion — trauma to the gingival tissue which frequently occurs on the facialsurfaces.

Gingival index — used to assess the severity of gingivitis based on color, consistency, andbleeding on probing.

Gingival recession — reduction of the height ofthe marginal gingiva to a location apical to thecementoenamel junction, resulting in root surfaceexposure.

Gingivitis — inflammation of the gingivaltissue with no apical migration of the junctionalepithelium beyond the cementoenamel junction.

Host defense — a person’s immune response toinvasion by pathogens or to treatment.

MEDLINE — a comprehensive database oflife sciences and biomedical bibliographicinformation.

Pathogenic products — products that can cause disease (such as specific bacteria).

Periodontal disease — inflammatory disease of the periodontium that results from the progression of gingivitis and is caused by specificmicroorganisms.

Supragingival plaque — plaque located above the gingival margin.

Subgingival plaque — plaque located below thegingival margin.

Systemic disease — a disease that affects anentire organism or bodily system.

Systematic review — a rigorous method ofreviewing original research to synthesize results,which results in a summary of the best evidence on a specific topic.

Tongue cleaning — the removal of debris andbacteria from the tongue.

Toothbrush abrasion — a pathologic wearingdown of the tooth as a result of improper toothbrush use.

History of the ToothbrushTooth cleaning devices date back thousands of years. Primitive configurations of the toothbrush,called “chewsticks” are mentioned in Chinese literature dating back to about 600 B.C. The toothbrush itself dates back to around 1000 ADin China. This brush is believed to have beenmade of hog’s bristles. When toothbrushes began to surface in Europe in the late 18th and19th centuries, they were too expensive for every person to afford. These brushes, often madeof gold, ivory or ebony, had replaceable heads.

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Finally, in the 1930’s, the affordable, plastichandle, nylon filament toothbrushes became available. Since then, synthetic materials havebeen the industry standard.2, 3 Until the 1970s,hard bristles were the norm due to a “harder you brush, the cleaner the teeth” mindset. This philosophy caused many cases of toothbrushabrasion to the teeth and gingival recession tosurrounding tissues. The invention of the nylonbrush is probably the biggest breakthrough in the history of oral hygiene products. In industrializedcountries, 80%-90% of people brush once ortwice a day.4

Mechanical toothbrushes were used in the 19thcentury. (Figure 1) Oddly enough, the power brush was not mass produced until the 1960’s. The push for power brushes was short-lived dueto the lack of evidence that the power brush performed as well if not better than a manualbrush.5 The power market resurfaced in the1980’s along with evidence that the powerbrushes had some superiority over manual brushes.6

Although the manual brush is still the primarymode of maintaining oral hygiene, most patientsdo not brush well and/or for an adequate amountof time. The power brushes were invented toovercome these barriers to maintaining good oral hygiene. In the 1960’s, the power brushes

were recommended primarily for those who werehandicapped or had limited manual dexterity. During the 1966 World Workshop in Periodontics, the use of power brushes was examined. Workshop participants stated: in persons who are not highly motivated and those who have difficulty with manual toothbrushing techniques, “the use of an electric brush with its standard movementsmay result in more frequent and better cleansingof the teeth.”7 Since the 1960’s, many new and improved designs have surfaced, including the oscillating or rotating brushes and brushes that function at high frequencies. During the 1998 European Workshop on Mechanical PlaqueControl, Weijden concluded: “Clinical trials over the past 10 years show that in controlled trials electric toothbrushes appear to be superior tomanual brushing.”6 Due to these findings, one can conclude that the recommendation for powerbrushes during the 1966 workshop for those with lack of motivation and limited dexterity has broadened to include more of the patients dentalprofessionals see every day.

Purpose/Indications of Power BrushesDental professionals examine patients every daywho exhibit gingivitis and/or periodontal disease. Many factors, such as family predisposition, smoking habits, systemic disease and hostdefense mechanisms, determine how patientsrespond to the bacterial plaque existing in their

Figure 1. Early Mechanical Brushes(Image presented with permission from Dr. Fridus van der Weijden)

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oral cavities. Dental professionals cannot control or change most of these risk factors; therefore, the focus is on the one evidence-based etiologic factor: the removal of bacterial plaque.8 It iswell documented that effective plaque removal prevents gingivitis and periodontitis. Dailyplaque removal by the patient accompanied by professional care should focus on theelimination of the pathogenic products in dental plaque. Studies have shown that the removal of supragingival plaque affects the subgingivalplaque biofilm; therefore, it reduces the clinical signs of inflammation.9 (Figure 2) Supragingival plaque removal can be accomplished by patientsin many ways.

Today’s toothbrush market is overwhelmingfor dental professionals as well as customers. Many toothbrushes are available with differentactions and features. Dental professionals are responsible for recommending brushes that motivate patients, boost brushing compliance, and are effective. It is understood that a patient’s response to any oral hygiene recommendation is based on their motivation and willingness tocomply. One study examined the compliancelevel of patients using powered toothbrushes unrelated to any social factors and found that36 months after the purchase of the powered

brush, 62% were still using the brush on a daily basis.10 Warren et al. studied the effectiveness of the Oral-B Ultra Plaque Remover in referenceto effectiveness and dental professional andpatients’ attitudes toward the brush. Eighty-fivepercent of the patients exhibited positive results, including reduction in plaque and improved gingival condition. One result of the study wasthat dental professionals (70%) stated they would be more likely to recommend the brush to their patients due to the changes that were evident in their patients’ oral health. Seventy-four percent ofthe patients perceived their oral health to be better than when they were using a manual brush. Themajority (88.9%) of the patients reported that they would continue using the brush after the study.11

A study conducted in 1998 had subjects comparethe Oral-B 3D power brush to a manual brush. The subjects perceived that the Oral-B 3D was more effective than the manual brush. They alsoreported an increase in their brushing time and effectiveness. It is well documented that patients do not brush long enough; power toothbrushes with timers may be an avenue for patients tobetter assess their brushing time. It has beenproven that more plaque can be removed in less time using power toothbrushes (Oral-B,Interplak, Blend-a-dent).12 With the evidence indicating patient preference and compliance withpower toothbrushes, dental professionals should feel confident that power brushes can motivate patients and boost brushing compliance.

When choosing a powered brush, the professional should examine the brush’s effect on:1. plaque2. gingivitis3. calculus4. stain

A systematic review of 29 articles covering2,547 subjects was done to compare manual and powered toothbrushes in the removal of plaque, the health of the gingiva, stain, calculus, dependability, adverse effects and costs. Thereview showed that power brushes that use a rotation oscillation action (Braun Oral-B and Phillips Jordan HP 735) removed more plaque and reduced gingivitis more effectively thanmanual brushes in the short and long term.13

(Table 1) (Figure 3)

Figure 2. Power Brush Bristles Disrupting Plaque(Image presented with permission from Dr. John Thomas and Oral-B Laboratories)

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Evidence suggests that power brushes can reduce the amount of stain and calculus present on teeth. A study compared the Braun Oral-B 3DExcel, the Sonicare power brush and a manualbrush. The two power brushes were used with conventional toothpaste, while the manual brushwas used with a tartar control toothpaste. Allthree modalities were effective in reducingcalculus and stain formation; however, the Oral-B3D Excel reduced calculus and stain more effectively than the other methods.1 This finding is amazing due to the fact that the manual brush was being used with tartar control toothpasteand the powered brush was not. The evidence supports the assertion that power toothbrushesthat use a rotation oscillation (such as the Oral-B) action are superior to manual brushes in plaqueremoval, reduction in gingivitis, calculus and stain formation.

Designs/MechanicsAs seen above, research supports the useof power brushes to motivate patients, boost compliance, reduce plaque, reduce gingivitis, and reduce calculus and stain formation. With

this evidence available, power brushes can be“mainstreamed” into the dental practice; however,power brushes are not “one size fits all.”14 Thereare various types of power brushes, categorized by the manner in which the brush head moves. (Table 2)

Brush head shapes are available for adults, children, orthodontic patients as well as forinterdental spaces. The brush shapes maybe round, conical or similar to traditional brush heads. Flat, bi-level, rippled or angled profiles exist. (Figure 4)

The brush heads for children are smaller toaccommodate the small oral cavity as well asthe developing dentition. (Figure 5) Interdental brushes are also available. (Figure 6)

The brush filaments are made of soft end-rounded nylon in various diameters. Thediameters correlate with the amount of softness. Power toothbrushes operate from a variety of power sources. A direct power source is when the brush connects to an electrical outlet. Some

Figure 3. Rotation Oscillation Action(Image presented with permission from Oral-B Laboratories)

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Figure 4. Various Brush Heads(Image presented with permission from Wilkins15)

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brushes have replaceable batteries. As the battery life is reduced, the brush speed alsoreduces. Power brushes with batteries shouldhave a watertight handle to avoid corrosionof the batteries. Disposable brushes are available where the battery cannot be replacedor recharged. Brushes with switches havea button that remains “on” until the button ispressed again. Other brushes have rechargeablebatteries, which are charged by sitting on astand that is connected to an electrical outlet. The speed of a powered brush varies from lowto high. This variance is dependent on themanufacturer and type of brush. For instance,power brushes with replaceable batteries usually

move slower than those with rechargeablebatteries.5 Some brushes offer a pressure sensor, which interrupts the brush movement to make patients aware when too much pressure is being applied to the tooth surface. (Figure 7)

It is well known that patients underestimate theamount of time they brush. Power brushes withtimers enable patients to assess the time spenton brushing.

SafetyPatients may use improper toothbrushingtechniques, abrasive toothpastes and hard bristlefilaments, which can damage the gingiva, dentin,

Figure 5. Child’s Brush Head Figure 6. Interdental Brush Head(Image presented with permission from Wilkins15)

Figure 7. Pressure Sensor (Oral-B Braun)(Image presented with permission from Oral-B Laboratories)

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and/or enamel.6 Two types of damage are called toothbrush abrasion and gingival recession. Toothbrush abrasion is defined as “pathologictooth wear as a result of a foreign substance.”(Figure 8) This type of abrasion is most commonly caused by traumatic toothbrushing. The teeth appear to have notches worn intothe teeth just above the gumline. Gingivalrecession is defined as “reduction of the heightof the marginal gingiva to a location apical to thecementoenamel junction, resulting in root surfaceexposure.” (Figure 9)

Gingival recession can be caused by many factors. Toothbrushing technique, frequency,duration, force of brushing, and the hardness of toothbrush filaments can all contribute to gingivalrecession.16 When making recommendations topatients, the dental professional should be certainof the safety of the product. Many studies have been performed that assess the safety of electrictoothbrushes.

Both toothbrush abrasion and gingival recession can be caused by excessive pressure while brushing. A study evaluated the brushing forceof individuals using a manual toothbrush andthree electric toothbrushes (Rotadent, Interplak,Braun D7). The results showed that considerablymore force was used by patients with the manualbrush; therefore less force was used with theelectric brushes.17 Some brushes, such as theBraun Oral-B plaque remover offer a pressure sensor, which makes patients aware when toomuch pressure is applied to the tooth. Fishmanconducted a review of published safety data on the Braun Oral-B plaque remover. Two short-

term studies, which used adults and children forsubjects, showed no evidence of soft or hard tissue trauma when using the Braun Oral-Bplaque remover. Seven studies estimated the effect of the powered brush in reducinggingivitis. These studies made the correlationbetween gingival bleeding, gingival index and softtissue trauma. In summary, if the gingiva was bleeding and the gingival index had increased, this would be indicative of soft tissue trauma. These detrimental effects were not noted in any of the seven studies reviewed.18 Dentinoevaluated gingival recession in 95 patients usingthe Braun Oral-B plaque remover or a standardmanual toothbrush. The results showed that theOral-B plaque remover did not cause gingivalrecession.19 Gingival abrasion can also occur due to toothbrushing. A study compared the incidence of gingival abrasion when 47 subjectsbrushed with a manual brush and the BraunOral-B plaque remover. When comparing thebrushes, gingival abrasion was comparable between the manual and electric toothbrush. Clinical studies consistently report no evidenceof clinically significant gingival abrasion, and anumber of studies that investigated safety reportno difference in the incidence of minor gingival abrasions associated with power and manual toothbrush use.20 According to the review of the literature above, the Oral-B powered brushshowed no evidence of harmful effects on thegingival or the root structure of the tooth.

Selection ParametersWith so many dental products on the markettoday, it is hard for dental professionals to stay abreast of the newest and greatest. The dental

Figure 8. Toothbrush Abrasion(Image presented with permission from Dr. Marty Spiller)

Figure 9. Gingival Recession(Image presented with permission from www.perio.com/b.html)

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professional as well as the patient has a wealth ofinformation at their fingertips. Recommendations should be based on the documented evidence of a product’s effectiveness, the dentalprofessional’s clinical experience, as well as the patient’s attitude toward their oral health andtheir willingness to try new products. The dental professional should search for research articlesthat assess the effectiveness of the product. Theresearch must be critically examined for bias or flaws in design. Patient readiness must be assessed to enhance the success of the new recommendation:1. Determine the patient’s perception of the

problem and their goals.2. Make sure the patient understands why and

how the product might benefit them.3. If the evidence is strong and the patient is

willing, make the recommendation.4. Evaluate the result, with the dental

professional and the patient working aspartners.

Using Science to Make RecommendationsSo where do dental professionals find the evidence of product effectiveness? There aremany literature resources available to dentalprofessionals. Many of these have editorialboards who review the submitted manuscripts for publication. A few of these titles include: The American Journal of Dentistry, The Journal of Clinical Dentistry, The Journal of Evidence-Based Dental Practice, The Journal of ClinicalPeriodontology, The Journal of Dental Hygiene and The Dental Assistant Journal. Journalscan be obtained through subscriptions, on-line or through a library affiliated with a dental, dental hygiene, or dental assisting program. Reviews of current literature are availablefrom many resources. Another source isindependent organizations such as the CochraneCollaboration. The Cochrane Collaboration is anorganization “that aims to help people make well informed decisions about healthcare by preparing, maintaining and promoting the accessibility ofsystematic reviews of the effects of healthcareinterventions”.21 For instance, a CochraneReview recently compared manual and powered toothbrushes in relation to the removal of plaque,the health of the gingivae, amount of staining and calculus, dependability and any adverse effects

and costs. Many databases were searched tocollect research on the topic. Some of these databases included: MEDLINE, EMBASE, and CINAHL. Companies were also contacted forresearch results. Dental professionals haveaccess to all these resources as well. Ask company representatives for published research that supports their products. Organizations such as the Cochrane Collaboration review all the literature and make conclusions the public and dental professionals can examine, apply andevaluate. In the recent Cochrane Review on powered toothbrushes, the reviewers found 29trials that included 2,547 patients!22

The Internet is a wealth of information for dentalprofessionals and patients. However, not everything found there is factual–be sure to checkthe sources. Other resources include colleagues,experts in the field, or continuing educationcourses. Still, the dental professional must evaluate the information, apply it and evaluate the outcome. The web also offers many resourcesfor information on products or links to productinformation. (Table 3).

Patient InstructionWhen teaching any new oral hygiene skill, thedental professional must assess the patient’sknowledge, attitudes, values and psychomotor skills. The patient’s particular situation, such astheir socio-economic status and stress levels also should be assessed. Establishment of new oral hygiene practices are dependent on activeparticipation of the patient. Patient to dental professional instruction is the best because itallows for immediate feedback. Self-instructionalmaterials can also be used by patients at homein addition to face-to-face instruction. The patient should be involved in the instructional process.23

One great way to facilitate patient involvement and compliance is with self-evaluation. Forexample: patients can use disclosing tablets after brushing to show the areas that need moreattention.

The advantage of powered brushes is the patient only has to focus on the placement ofthe brush, not the brushing action; therefore the powered brush works well for patients with limiteddexterity and those who are ineffective brushers with a manual brush. It is imperative that the

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dental professional review the manufacturer’s instructions due to the vast number of designsavailable. Review the manufacturer’s suggestions for use and care of the brush.

General instructions for power brushes includeselecting a brush with soft end-rounded filaments and a dentifrice with minimum abrasivity. Instruct the patient to spread the dentifrice over severalteeth before starting to brush to prevent splashing of the dentifrice when the brush is turned on. The patient should vary the brush position to reacheach tooth surface, including the distal, facial,mesial and lingual surfaces. The angulation mayneed to be altered for access to malpositionedteeth. For brushing the occlusal surfaces, placethe brush with filaments pointing into the occlusal pits at a right angle. The patient can movethe brush in a slight circular motion while the filaments are in the occlusal pits or can press moderately (not bending the bristles) so thefilaments go straight into the pits and fissures. The strokes for the occlusal surfaces are sharp and quick. The brush should be lifted after eachstroke to dislodge any loosened debris.

Tongue cleaning can also be done with a powered brush. Tongue cleaning is important because it retards plaque formation and totalplaque accumulation. Some brushes havespecific brush heads designed for tongue cleaning. With the tongue extruded, the brush should be placed at a right angle to the midlineof the tongue with the bristles pointing toward the throat. With light pressure, the sides of the filaments are drawn forward toward the tip of thetongue. This procedure should be repeated 3-4 times until the tongue surface is clean.15

SummaryDental professionals today can be overwhelmedby the number of products surfacing on the market daily. Patients are more educatedand asking more questions about theircare. Technological advances oblige dental professionals to seek information that will enablethem to make the best recommendations based on proven product effectiveness, their own clinicalexperience, and patient values.

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To receive Continuing Education credit for this course, you must complete the online test. Pleasego to www.dentalcare.com and find this course in the Continuing Education section.

Course Test Preview1. Power brushes were first seen in mass production in the:

a. 1930’sb. 1950’sc. 1960’sd. 1970’se. 1980’s

2. Power brushes were invented to:a. Overcome domination of the manual toothbrush marketb. Improve brushingc. Encourage patients to brush longerd. a, b, ce. b, c

3. In the early days of power brushes, they were primarily recommended for those who were handicapped and had limited dexterity.a. Trueb. False

4. Which of the following factors determine how patients respond to bacterial plaque?a. Host defense mechanismsb. Systemic diseasec. Family predispositiond. Smoking habitse. All of the above

5. Powered brushes focus on the elimination of pathogenic products, therefore, reducing the signs of inflammation.a. Trueb. False

6. Thirty-six months after the purchase of a powered brush ___% were still using the brush on a daily basis.a. 30b. 45c. 62d. 70e. 75

7. In a study where patients used the Oral-B 3D, they reported an increase in their brushing time and effectiveness.a. Trueb. False

8. Less plaque is removed using a power brush even when brushing longer.a. Trueb. False

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9. Power brushes using the _____ action have been proven to reduce more plaque and gingivitis than a manual brush.a. Circularb. Counter oscillationc. Side to sided. Up and downe. Rotation oscillation

10. One study compared power brushes to a manual brush. The manual brush used tartar control toothpaste while the power brushes used conventional toothpaste. The results showed one of the powered brushes to be superior even though conventional toothpaste was used.a. Trueb. False

11. Which of the following brush heads are available for the powered brush?a. Interdentalb. Adultc. Childrend. Orthodontic patientse. All of the above

12. The best brush filaments to recommend are hard, end-rounded and nylon.a. Trueb. False

13. The speed of a battery-powered brush is not affected as the battery life is reduced.a. Trueb. False

14. Some power brushes are available with pressure sensors to make patients aware when too much pressure is being applied to the tooth surface.a. Trueb. False

15. Toothbrush abrasion and gingival recession can be caused by excessive pressure when toothbrushing.a. Trueb. False

16. Research has shown that more pressure is used when patients brush with a manual brush compared to a power brush.a. Trueb. False

17. Evidence suggests that power brushes can increase the amount of stain and calculus on the teeth.a. Trueb. False

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18. Research has shown that the Braun Oral-B power brush does not cause gingival recession.a. Trueb. False

19. Which of the following should be considered when making recommendations to patients?a. The best evidenceb. Clinical experiencec. Patient’s valuesd. Patient’s willingnesse. All of the above

20. To ensure patient compliance, the dental professional should make sure:a. The patient understands why the product is neededb. The patient knows how the product might benefit themc. The patient is willing to make the changed. The patient is involved in the evaluation of the product and its effectivenesse. All of the above

21. Self-instructional materials are the best method to teach patients new oral hygiene methods.a. Trueb. False

22. When using a power brush, the patient has to focus on the placement of the brush, not the brushing action.a. Trueb. False

23. Power brushes should not be used to clean the tongue.a. Trueb. False

24. Which of the following are methods taught to patients using power brushes?a. Use a dentifrice with minimum abrasivity

b. Spread dentifrice over several teeth before turning the brush onc. Vary the brush position to reach each tooth surfaced. Brush occlusal pits by pointing bristles at a right angle into the pitse. All of the above

25. Clinical trials have shown that power brushing appears to be superior to manual brushing.a. Trueb. False

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References1. Sharma NC, Galustians HJ, Qaqish J, Cugini M, Warren PR. The effect of two power toothbrushes

on calculus and stain formation. Am J Dent. 2002 Apr;15(2):71-6. Erratum in: Am J Dent. 2002 Oct;15(5):348.

2. Alexander JF. “Toothbrushes and Toothbrushing”, in Menaker, L., ed.: The Biologic Basis of Dental Caries. Hagerstown, MD: Harper & Row, 1980, pp. 482-496.

3. Fischman SL. “Oral hygiene products: How far have we come in 6000 years?” Periodontology 2000 15 (1997): 7-14.

4. Saxer UP, Yankell SL. Impact of improved toothbrushes on dental diseases. II. Quintessence Int.1997 Sep;28(9):573-93.

5. Frandsen A. “Mechanical oral hygiene practices.” In: Loe H, Kleinman D V. (eds) Dental Plaque Control Measures and Oral Hygiene Practices. Oxford: IRL Press, 1986, pp. 93-116.

6. Van der Weijden GA, Timmerman MF, Danser MM, et al. “The role of electric toothbrushes: advantages and limitations.” In: Lang NP, Attstrom R, Loe H (eds.). Proceedings of the EuropeanWorkshop on Mechanical Plaque Control. Berlin: Quintessence Verlag, 1998, pp. 138-155.

7. Greene JC. World Workshop in Periodontics, eds. Ramfjord, S.P., Kerr, D.A. & Ash, M.M., Ann Arbor, MI.: American Academy of Periodontology, 1966, pp. 399-443.

8. Garmyn P, van Steenberghe D, Quirynen. “Efficacy of Plaque Control in the Maintenance of GingivalHealth: Plaque Control in Primary and Secondary Prevention.” In: Lang NP, Attstrom R, Loe H (eds.). Proceedings of the European Workshop on Mechanical Plaque Control. Berlin: Quintessence Verlag, 1998, pp. 107-120.

9. Smulow JB, Turesky SS, Hill RG. The effect of supragingival plaque removal on anaerobic bacteria deep periodontal pockets. J Am Dent Assoc. 1983 Nov;107(5):737-42.

10. Stalnacke K, Soderfeldt B, Sjodin B. Compliance in use of electric toothbrushes. Acta OdontolScand. 1995 Feb;53(1):17-9.

11. Warren PR, Ray TS, Cugini M, Chater BV. A practice-based study of a power toothbrush:assessment of effectiveness and acceptance. J Am Dent Assoc. 2000 Mar;131(3):389-94.

12. Van der Weijden GA, Timmerman MF, Nijboer A, Lie MA, Van der Velden U. A comparative study ofelectric toothbrushes for the effectiveness of plaque removal in relation to toothbrushing duration.Timerstudy. J Clin Periodontol. 1993 Aug;20(7):476-81.

13. Heanue M, Deacon SA, Deery C, Robinson PG, Walmsley AD, Worthington HV, Shaw WC. Manualversus powered toothbrushing for oral health. Cochrane Database Syst Rev. 2003;(1):CD002281.

14. Hemingway NJ, Guest editorial: “Mainstreaming power products into your practice.” J Practical Hyg10(5) (2001): 36.

15. Ray TS. Oral Infection Control:Toothbrushes and Toothbrushing, in Wilkins, E.M.: Clinical Practice ofthe Dental Hygienist, 9th ed. Philadelphia, Lippincott Williams & Wilkins, 2004. (In Press)

16. Darby ML, Walsh MM. Dental Hygiene Theory and Practice, 2nd Ed. St. Louis: Saunders Inc., 2003, p.1135, 1156.

17. van der Weijden GA, Timmerman MF, Reijerse E, Snoek CM, van der Velden U. Toothbrushing forcein relation to plaque removal. J Clin Periodontol. 1996 Aug;23(8):724-9.

18. Fishman SL. “Review of Published Safety Data: Braun Oral-B Plaque Remover Toothbrush.”Periodontal Insights Sept (1998): 17-19.

19. Dentino AR, RL Van Swol, GM Derderian, MR Wolf, PR Warren, “Comparative Evaluation of the Safety of a Powered vs. a Manual Toothbrush Over One Year.” Amer. Acad. Perio Ann MeetingAbstract #208, 1998.

20. Danser MM, Timmerman MF, IJzerman Y, Bulthuis H, van der Velden U, van der Weijden GA. Evaluation of the incidence of gingival abrasion as a result of toothbrushing. J Clin Periodontol. 1998Sep;25(9):701-6.

21. Cochrane Handbook for Systematic Reviews of Interventions (formerly the Reviewers’ Handbook).Clarke M, Oxman A. (editors) (4.2.0 updated March 2003). The Cochrane Library [Issue 2]. 4-30-2003. Oxford: Update Software. Internet link, July 2006.

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22. Manual versus powered toothbrushing for oral health (Cochrane Review). Heanue M, Deacon S, Deery C, Robinson P, et al. Cochrane Oral Health Group, editor. Cochrane Library, Issue 2, 2003.Oxford, The Cochrane Library. Internet link, July 2006.

23. Renvert S, Glavind L. “Individualized Instruction and Compliance in Oral Hygiene Practices: Recommendations and Means of Delivery.” In: Lang NP, Attstrom R, Loe H (eds.). Proceedings of the European Workshop on Mechanical Plaque Control, Berlin: Quintessence Verlag, 1998, pp. 107-120.

Suggested Readings• Bowen D. An evidence-based review of power toothbrushes. Comp of Cont Ed in Oral Hygiene.

Vol. 9, No. 1. 2002• Bowen D, Forrest J. “Solving Puzzling Clinical Questions.” RDH May (2003): 34, 36, 38, 40, 100.• Haffajee AD, Arguello EI, Ximenez-Fyvie LA, Socransky SS. Controlling the plaque biofilm. Int Dent

J. 2003;53 Suppl 3:191-9.• Proceedings of the European Workshop on Mechanical Plaque Control. Lang NP, Attstrom R, Loe

H. Switzerland: Quintessence, 1998. Internet link, July 2006.• Slots J. Update on general health risk of periodontal disease. Int Dent J. 2003;53 Suppl 3:200-7.• Sharma NC, Galustians HJ, Qaqish J, Cugini M. Safety and plaque removal efficacy of a battery-

operated power toothbrush and a manual toothbrush. Am J Dent. 2001 Nov;14 Spec No:9B-12B.• van der Weijden GA, Timmerman MF, Piscaer M, IJzerman Y, van der Velden U. A clinical

comparison of three powered toothbrushes. J Clin Periodontol. 2002 Nov;29(11):1042-7.• Warren PR, Cugini M, Marks P, King DW. Safety, efficacy and acceptability of a new power

toothbrush: a 3-month comparative clinical investigation. Am J Dent. 2001 Feb;14(1):3-7.

About the Author

Ginger B. Mann, BSDH, MSMs. Mann was a clinical associate professor at the UNC School of Dentistry at Chapel Hill for tenyears. She graduated from Old Dominion University in 1991 with a Master’s Degree in DentalHygiene Education. During her ten years at UNC she was responsible for teaching numerouscourses, including Dental Health Education and Clinical Coordinator for second year dental hygiene students. Ms. Mann has received numerous teaching excellence awards. She is a published author and presents continuing education courses. Currently she is the project coordinator for numerous community projects focusing on preschool aged children. Ms. Mann is also a part-time clinical instructor at Wake Technical Community College and an adjunct faculty at the UNC School of Dentistryat Chapel Hill.

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