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hygiene tribuneDental Tribune Middle East & Africa Edition | November-December 2014 1B From novel to normal Review of power toothbrushes considers safety issues > Page 2B By Shelly L. Campbell, RDH, MPH T he cabbage soup diet. NASA-inspired space food sticks. The belt massager machine to “jiggle away the pounds.” How are these things connected? These health and fitness offerings from the 1960s quickly faded from the public eye after failing to live up to their hype, or by causing safety con- cerns. Another health improvement introduction in the ’60s – the electric toothbrush – could have met a similar fate because early prototypes were bulky, unreli- able, and even capable of caus- ing electric shock. But unlike other inventors of health fads destined for obscurity, undaunt- ed electric toothbrush manufac- turers continued to evolve more streamlined and technologically advanced power toothbrush models over the next several decades. Today, many children and adults havepermanentlyreplacedtheir manual brush with an electric model, having been won over by the electric brush’s reliable cleaning efficiency and ease of use. Value-based battery brush- es, as well as premium multi- feature rechargeable electric toothbrushes (also referred to as power toothbrushes), are now mainstream, their popularity reflected in exponential growth over the last decade.1 Interest- ingly, a recent survey showed only 14% of women surveyed would consider giving up their power brush as a budget-saving sacrifice.2 It’s safe to say that power brushes are here to stay. Dental professionals see im- provements in the oral hygiene and gingival health of patients who use power toothbrushes, both anecdotally and in large surveys.3,4 Additionally, clinical research over several decades has shown that in general, pow- er brushes provide noticeable plaque removal benefits, with one brush technology — oscil- lating-rotating (O-R) — standing apart when statisticians crunch the numbers to analyze the re- sults of the clinical research.5,6,7 In 2005, the wellrespected in- ternational Cochrane Collabo- ration Oral Health Group pub- lished a review of 42 of these published clinical investigations, where power toothbrushes, including those with counter- rotational (e.g., Interplak®), oscillating-rotating (e.g., Braun/ Oral-B®), and side-to-side (e.g., Sonicare®) modes of ac- tion, were directly compared to manual toothbrushes for clinical effectiveness in thousands of pa- tients. From their systematic re- view and meta-analysis [see Sys- tematic analysis in a nutshell], the Cochrane Group concluded that one brush type produced statistically significantly supe- rior benefits: “Powered tooth- brushes with a rotation oscilla- tion action reduce plaque and gingivitis more than manual toothbrushing.”7 The safety question Power toothbrush effective- ness is seldom debated, but are safety concerns involved? Could the documented connection be- tween power toothbrushing and greater patient compliance8-11 lead to more gingival abrasion caused by longer brushing times or increased brushing frequen- cy? Does power toothbrushing result in more hard tissue wear compared to manual brushing? Will enthusiastic power brush users apply too much force and compromise their gingival tis- sues or promote recession? Although the Cochrane review didn’t evaluate safety as the pri- mary objective, it did state, “Any reported side effects were lo- calized and temporary.”7 Other studies and literature reviews have generally come to the same conclusion.12-14 Case closed. Or is it? Lingering questions about the safety of power brushes on hard and soft tissues have persisted in some quarters.15 Hygienists and dentists know their patients take their professional product recommendations seriously, and they want to ensure they’re sug- gesting the most effective and safe oral commercial products and regimens. The goal should be evidence- based recommendations as op- posed to speculation, but keep- ing up with all of the literature and assessing the quality and relevance of each individual power toothbrush study re- quires a significant commitment of time and effort for profession- als who already have a lot on their plates. In search of an answer Systematicreviewsofhealthtop- ics (see sidebar) can be a great asset to busy professionals who don’t have time to comb through the literature themselves. To address the power toothbrush safety question, a recently pub- lished systematic review in the Journal of Periodontology considered theoretical safety concerns about power versus manual toothbrushes through a comprehensive analysis of all relevant published reports. The article is “Safety of Oscillating- Rotating Powered Brushes Com- pared to Manual Toothbrushes: A Systematic Review” by Van Der Weijden et al.16 Here are the key findings: What research was included? O-R power toothbrush safety research was chosen for com- parison to manual toothbrushes basedontheCochranefindings.7 All published English language titles and abstracts through May 2010 were included in a full search of three major databases (e.g., PubMed-Medline), result- ing in 899 potential publications that were evaluated, with 35 meeting all predetermined eligi- bility criteria. The 35 studies in the final review were designed to measure soft and/or hard tis- sue safety by tracking either pri- mary (gingival recession) or sec- ondary parameters (observed or reported adverse events or hard tissue effects), or a surrogate pa- rameter (stained gingival abra- sion or brushing force). What patients and tooth- brushes were involved? There was considerable diver- sity among the nearly 2,000 patients included in the 31 ran- domized and blinded human subject clinical trials, which ranged from four days to three years. These included adults with and without elevated plaque, gingivitis and/or bleed- ing, children with and without orthodontia, and periodontal pa- tients. Braun/Oral-B or Philips/ Jordan manufactured the power brushes in the reviewed stud- ies, while 10 various comparator manual brushes were also rep- resented. The majority of tooth- brushing was unsupervised in the home setting. Were O-R power toothbrushes associated with more gingival recession? No.Ameta-analysis[seesidebar] of two six-month clinical trials focusing exclusively on gingival recession showed there were no significant recession differences between the power and manual toothbrush groups. Did O-R power brushes use more force than manual brushes? No. In the two force investiga- tions, the average O-R power brush brushing force was sig- nificantly lower than the aver- age manual toothbrush brush- ing force. Was there more gingival abra- sion with use of the O-R power toothbrushes? Gingival abrasions that could potentially be caused by tooth- brushing were found in both the manual and O-R power tooth- brush groups, but the authors of the published reports de- scribed them as either negligi- ble/not clinically significant, or occurring with about the same frequency in the manual and power brush groups, and not significantly different when sta- tistically tested. How important is in vitro data? Did the in vitro studies show greater wear with O-R brushes? Since there is currently no stand- ard methodology with enough sensitivity for long-term clinical assessment of hard tissue brush- ing damage, in vitro studies are a valuable step in identifying potential safety concerns (like abrasion potential) that are chal- lenging to discover clinically. Four in vitro (laboratory) inves- tigations met eligibility criteria and were included in the review. The three trials evaluating hu- man dentin found similar or less wear with use of the O-R power toothbrushes, compared with manual brushes used under simulated clinical conditions. The authors of the fourth study suggested that bovine enamel loss after an acidic attack may be increased with use of cer- tain power brushes when used at the same brushing force. But understanding the clinical im- plications is difficult, given that toothbrushing forces have been