Evaluation of the Efficacy of Manual Toothbrush Versus Power Toothbrush in Reduction of Gingivitis: A Comparative Clinical Study.

Background: In our study, we compare the power toothbrush with the manual toothbrush and the results showed were contradictory. Where few studies have reported that power toothbrushes are superior, other studies showed that both are equally efficacious in removing dental plaque. Aims: The present study was conducted to evaluate and compare the efficacy of manual toothbrush with an electric toothbrush in reducing dental plaque and gingivitis. Materials and
Methods: The study included a total of 56 subjects which were randomly divided into two groups of 28 subjects each. At week 1, disclosing agent (two-tone solution) was used to detect plaque, and Loe and Silness Gingival Index were used to assess gingival scores. Oral hygiene instructions and brushing were also reinforced. A similar protocol was repeated at one, two, and six weeks. The collected data were subjected to statistical evaluation.
Results: At two weeks, the plaque score for manual and power toothbrushes were 60.253 ± 20.672 and 44.031 ± 16.484, respectively, and this difference was statistically significant with P = 0.0020. At six weeks, plaque scores for manual and power toothbrushes were 43.784 ± 22.647 and 20.489 ± 10.336, respectively, and were statistically significant (P < 0.0001).
Conclusion: The present study concludes that powered toothbrush has added advantages of improved oral hygiene compared to manual toothbrush concerning plaque reduction. This can be attributed to predefined power and force which can effectively remove plaque, calculus, and improved gingival health. Copyright:

INTRODUCTION

One of the most common etiological factors associated with inflammatory gingival and periodontal diseases as well as with dental caries is dental plaque. The cause–effect relationship between the presence of dental plaque and the development of gingivitis was established by Vatsa R et al. in his classic study.[1] Oral health is preserved well in subjects with good plaque control. Plaque is deposited mainly in the natural retentive areas as gingival margins, proximal tooth surfaces, and tooth defects. However, these retentive areas of the oral cavity are well protected via cleansing and flushing mechanisms that exist naturally in the oral cavity. Hence, stress should be posted on the effectiveness of mechanical plaque control devices on maintaining oral hygiene via plaque removal in these retentive areas.[2]

A widely accepted and efficacious method of plaque control is the mechanical plaque removal aids. However, mechanical plaque control measures render be less effective, owing to them being time-consuming, difficult to master, and tedious. The average individual only removes approximately 50% of the dental plaque effectively. The first electric toothbrush driven by motor was first shown in 1968 at the convention of the American Dental Association. Since then, various researchers have focused on the comparative evaluation of manual toothbrushes to power toothbrushes concerning efficacy. However, despite inconclusive results of these comparative studies, all trials have concluded the least efficacy of all mechanical plaque control aids on mandibular molar's lingual surfaces.[3]

Plaque control in these areas can be improved and is governed by the patient's skill, bristle diameter, bristle length, bristle material, brush design, and brush head. These requirements are not fulfilled via a manual toothbrush. Hence, powered toothbrushes were introduced. The basic principle of powered toothbrush functioning is acoustic microstreaming where rapid bristle vibration leads to the generation of hydrodynamic forces in the liquid medium that disrupt plaque from the surfaces of teeth.[4]

Powered toothbrush driven electrically was developed to copy back and forth motion of the various brushing techniques. Early developed power toothbrushes were made to perform elliptical or circular motions. Recently, these brushes show rotating and oscillating motions. Since the introduction of the power toothbrush, it has been constantly compared with a manual toothbrush in various study designs and setups.[5] However, the results showed were inconclusive and contradictory: where few studies reported that powered toothbrushes are superior to manual tooth brushes, other studies showed that both are equally efficacious in removing dental plaque. Hence, the present study was conducted to evaluate and compare the efficacy of a manual toothbrush with an electric toothbrush in reducing dental plaque and gingivitis.

MATERIALS AND METHODS

The present, prospective, randomized clinical study was conducted at Mahatma Gandhi Postgraduate Institute of Dental Sciences, Pondicherry, India. The study population comprised of subjects visiting the outpatient department of Periodontology of the Institute. The study included a total of 56 subjects from both genders within the age range of 18 years to 29 years and with a mean age of 21.46 ± 3.78 years. All included subjects were randomly divided into two groups of 28 subjects each using the flip of the coin method. All subjects of both the groups were given the same dentifrices for a six-week period for both manual and powered toothbrushes. Modified bass technique was used with manual brush and brush perpendicular to the gingival margin for powered toothbrush.

The inclusion criteria for the study were subjects with no medical history, good oral hygiene, moderate gingivitis with a minimum of 25% sites with bleeding on probing, all teeth present (except third molars), and subjects willing to participate in the study. The exclusion criteria were subjects with mucogingival deformities, medical history, alcoholics, smokers, tobacco chewers, subjects using mouthwashes and interdental cleaning aids, subjects undergoing orthodontic treatment, drugs affecting gingival tissues, subjects with lack of manual dexterity, and subjects not willing to participate in the study.

After explaining the detailed study design and final inclusion, detailed history and demographics of all the subjects were recorded with consent. This was followed by an intraoral clinical examination. All teeth were examined at six surfaces including distobuccal, mid-buccal, mesiobuccal, disto-lingual, mid-lingual, and mesiolingual. Similar brushes were given to all subjects of one group to avoid bias. To make baseline scores zero, scaling and polishing were done for all subjects and they were explained about brush usage twice daily for two minutes. The subjects were recalled at one, two, and six weeks for assessment.

At week one, disclosing agent (two-tone solution) was used to detect plaque, and Loe and Silness Gingival Index[6] was used to assess gingival scores. Oral Hygiene Index-Simplified[7] (OHI-S) and Plaque Index[8] were used to assess oral hygiene. Oral hygiene instructions and brushing were also reinforced. A similar protocol was repeated at one, two, and six weeks.

The collected data were subjected to the statistical evaluation using SPSS software version 21 (Chicago, IL, USA) and paired t test. The data were expressed in percentage and number, and mean with standard deviation. The level of significance was kept at P < 0.05.

RESULTS

The present, prospective, randomized clinical study was conducted to evaluate and compare the efficacy of a manual toothbrush with an electric toothbrush in reducing dental plaque and gingivitis. The study included a total of 56 subjects from both genders within the age range of 18 years to 29 years and with a mean age of 21.46 ± 3.78 years. All included subjects were randomly divided into two groups of 28 subjects each.

On assessing OHI-S, plaque, and gingival index in subjects using a manual toothbrush, it was seen that OHI-S was 0.234 ± 0.154 at week 1 which was 0.408 ± 0.244 at week 6. The plaque index reduced from 9.723 ± 8.697 at week 1 to 26.17 ± 19.465 at week 6, whereas the gingival index reduced from 0.0724 ± 0.086 to 0.116 ± 0.098 from week 1 to week 6. These changes for all three indices were statistically significant with P < 0.0001 [Table 1].

Table 1

Comparison of oral hygiene index, plaque index, and gingival index at different time intervals in subjects using a manual toothbrush

Time Period Comparison	OHI-S (Oral Hygiene Index-Simplified)		Plaque Index		Gingival Index
	Mean±S.D.	P	Mean±S.D.	P	Mean±S.D.	P
1-2 weeks	0.234±0.154	0.0001	9.723±8.697	0.0001	0.0724±0.086	0.0001
2-6 weeks	0.177±0.166	0.0001	16.44±16.083	0.0001	0.040±0.043	0.0001
1-6 week	0.408±0.244	0.0001	26.17±19.465	0.0001	0.116±0.098	0.0001

The present study also assessed OHI-S, plaque, and gingival index in subjects using powered toothbrushes. It was seen that OHI-S was 0.323 ± 0.244 at week 1 which was 0.509 ± 0.219 at week 6. The plaque index reduced from 21.896 ± 17.118 at week 1 to 45.442 ± 24.006 at week 6, whereas the gingival index reduced from 0.084 ± 0.045 to 0.128 ± 0.076 from week 1 to the end of the study. These changes for all three indices were statistically significant with P < 0.0001 [Table 2].

Table 2

Comparison of oral hygiene index, plaque index, and gingival index at different time intervals in subjects using a powered toothbrush

Time Period Comparison	OHI-S (Oral Hygiene Index- Simplified)		Plaque Index		Gingival Index
	Mean±S.D.	P	Mean±S.D.	P	Mean±S.D.	P
1-2 weeks	0.323±0.244	0.0001	21.896±17.118	0.0001	0.084±0.045	0.0001
2-6 weeks	0.189±0.192	0.0001	23.544±14.179	0.0001	0.046±0.053	0.0001
1-6 weeks	0.509±0.219	0.0001	45.442±24.006	0.0001	0.128±0.076	0.0001

On comparing the plaque scores of the manual toothbrush with powered toothbrush, it was seen that at two weeks the plaque score for manual and power toothbrushes were 60.253 ± 20.672 and 44.031 ± 16.484 respectively, and this difference was statistically significant with P = 0.0020. At six weeks, plaque scores for manual and powered toothbrushes were 43.784 ± 22.647 and 20.489 ± 10.336 respectively, and were statistically significant (P < 0.0001) [Table 3].

Table 3

Comparison of plaque scores in manual versus powered toothbrush at two and six weeks of the study

Time Period Comparison	Manual Toothbrush (Mean±S.D.)	Power Toothbrush (Mean±S.D.)	P
2 weeks	60.253±20.672	44.031±16.484	0.0020
6 weeks	43.784±22.647	20.489±10.336	<0.0001

DISCUSSION

The present clinical study was conducted to evaluate and compare the efficacy of a manual toothbrush with an electric toothbrush in reducing dental plaque and gingivitis. The study included a total of 56 subjects from both genders within the age range of 18 years to 29 years and with a mean age of 21.46 ± 3.78 years. All included subjects were randomly divided into two groups of 28 subjects each.

The study results showed that with regard to the OHI-S, plaque, and gingival index in subjects using a manual toothbrush, OHI-S was 0.234 ± 0.154 at week 1 which was 0.408 ± 0.244 at week 6; the plaque index reduced from 9.723 ± 8.697 at week 1 to 26.17 ± 19.465 at week 6, whereas the gingival index reduced from 0.0724 ± 0.086 to 0.116 ± 0.098 from week 1 to week 6. These changes for all three indices were statistically significant with P < 0.0001. These results were consistent with the studies of Rosema et al.[9] in 2013 and Goyal et al.[10] in 2011 where comparable efficacy of manual toothbrushes was seen in reducing plaque and improving gingival health.

Concerning OHI-S, plaque, and gingival index in subjects using powered toothbrushes, it was seen that OHI-S was 0.323 ± 0.244 at week 1 which was 0.509 ± 0.219 at week 6. The plaque index reduced from 21.896 ± 17.118 at week 1 to 45.442 ± 24.006 at week 6, whereas the gingival index reduced from 0.084 ± 0.045 to 0.128 ± 0.076 from week 1 to the end of the study. These changes for all three indices were statistically significant with P < 0.0001. These findings were in agreement with the findings of Sharma et al.[11] in 2012 and Dorfer et al.[12] in 2016 where comparable results were seen for powered toothbrushes on various oral hygiene, plaque, and gingival indices.

The present study also compared the manual toothbrush to powered toothbrush concerning the plaque scores, it was seen that at two weeks, the plaque score for manual and powered toothbrushes was 60.253 ± 20.672 and 44.031 ± 16.484 respectively, and this difference was statistically significant with P = 0.0020. At six weeks, plaque scores for manual and power toothbrushes were 43.784 ± 22.647 and 20.489 ± 10.336 respectively, and were statistically significant (P < 0.0001). These results were comparable to the studies of Sicilia et al.[13] in 2002 and Lazarescu et al.[14] in 2003 where a similar comparison was seen in plaque removal efficacy of manual versus powered toothbrushes.

CONCLUSION

Within its limitations, the present study concludes that powered toothbrush has added advantages of improved oral hygiene compared to manual toothbrush concerning plaque reduction. This can be attributed to predefined power and force which can effectively remove plaque, calculus, and improved gingival health. However, the present study had few limitations including smaller sample size, short recall, no dentifrices consideration, geographical area biases, recall bias, and single-institution nature. Hence, more longitudinal and prospective studies with larger sample sizes and longer monitoring periods are needed to reach a definitive conclusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.