Manual vs Powered Toothbrushing in Patients With Fixed Orthodontic Appliances


Considering the exponential growth of information on any given subject, clinicians will discover that evidence-based practice gets easier. However, there are countless, low-quality studies and reviews online that confuse readers and should be avoided.

©milanmarkovic78/Adobe Stock

©milanmarkovic78/Adobe Stock

I spend a lot of time educating patients and even strangers I meet in the personal care section of retail stores. For many years, I worked for a dentist who liked to contradict my oral hygiene recommendations for orthodontic and other patients, young and old. It left me feeling unvalued, and I stayed in that clinical position longer than I should have. Granted, my recommendations weren’t always based on scientific evidence; instead, they were sometimes based on peer preference as discussed on social media blogs, continuing education courses, or patient outcomes over time. My employer would often recommend a powered toothbrush for ortho patients, and my preference for most adults, teens, and children was an oral irrigator as an adjunct to manual toothbrushing. My employer and I usually brushed off our differences, but sometimes we confused our patients or their caregivers in the process.

The Dental Elf is a daily, online blog I follow that is invaluable in helping dental professionals keep up with the latest evidence on a variety of dental topics. The UK editor keeps us abreast of key systematic reviews and clinical trials and guides us in selecting high-quality patient information. On November 4, I read a summary of a systematic review (SR) and meta-analysis comparing powered vs manual toothbrushing in patients with fixed orthodontic appliances.1 This SR piqued my curiosity mainly because of my previous association with the topic and my preference for ethical scientific reporting, so I was eager to read this particular summary.

Oral hygiene maintenance is a dental hygienist’s delight and is consistent with our educational goals. Most hygienists I know are hungry for new evidence, and patients always appreciate hearing about new research to support a recommendation. Telling patients how and why I search for high-quality evidence has always helped to build trust with patients.

High-quality or low-quality evidence refers to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to rating the quality of research evidence and to the body of evidence, not individual studies.

Considering the exponential growth of information on any given subject, a busy clinician will discover that evidence-based practice gets easier every year as technology improves and alliances are formed, making it simpler to search for information. I personally find it very easy now to search for high-quality research compared to 5 to 10 years ago. However, there are countless, low-quality studies and reviews online that confuse readers and should be avoided.

Today’s SRs and meta-analyses, if they are high quality, explain in great detail the literature search methodology. In this particular SR, in which the objective of the data analysis was to compare powered versus manual toothbrushes for oral maintenance in orthodontic patients, the following methods were reported:

Electronic databases, including Medline, Scopus, Google Scholar, PubMed, Web of Science, the Cochrane Oral Health Group Trials Register, and the Cochrane Central Register of Controlled Trials, were searched without language restrictions. Randomized clinical trials directly comparing manual and powered toothbrushing including patients with fixed orthodontic appliances reporting predefined outcomes with a follow-up period of at least 4 weeks were included. Using predefined data extraction forms, 2 authors independently undertook data extraction with conflict resolution by the third author. Quality assessment was based on the Cochrane risk-of-bias tool, and overall evidence was assessed using the GRADE system. A random-effects meta-analysis combined the treatment effects across studies.1

Results were obtained from 5 clinical trials; 8 trials were excluded. (Investigators who conduct these reviews learn how to recognize and discard poor-quality clinical trials). Investigators found slight differences in plaque index reduction at 4- and 8-week follow-ups that favored manual toothbrushing, but results were not statistically significant. Examining gingival index reduction at 4 weeks and 8 weeks showed slight differences that favored powered toothbrushing, but again, results were not statistically significant. The overall quality of evidence surrounding this SR, based on available evidence, is considered low to moderate. The authors of this SR concluded that there is no difference between manual and powered toothbrushing at 4 weeks and 8 weeks for fixed orthodontic patients, but the evidence was rated as low quality and was extracted from few studies.1

After reading this SR summary, how would it affect your recommendations to a patient with a fixed orthodontic appliance? Here’s where clinical expertise, patient need, and values come into play, all of which are part of an evidence-based recommendation. As an experienced clinician who has deplaqued and educated thousands of fixed orthodontic patients, I recognize that the entire clinician/patient experience requires shared engagement and commitment, with scientific evidence being only part of the process.

Most astute clinicians are very aware of the importance of patient compliance with oral biofilm reduction to prevent the development of gingivitis, demineralization, and white spot lesions and of the importance of pH balance in the demineralization process. We are often really good at educating caregivers and patients about the prevention of dental caries and gingivitis, but engaging patients in the process is always more challenging. Make team decisions about how to engage patients and caregivers in all areas that impact oral hygiene maintenance including diet and be sure that every patient has a customized orthodontic care plan. In addition, keep your eye on the science, and read both TheDental Elfand Cochrane Oral Health reviews.


ElShehaby M, Mofti B, Montasser MA, Bearn D. Powered vs manual tooth brushing in patients with fixed orthodontic appliances: a systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2020;158(5):639-649. doi:10.1016/j.ajodo.2020.04.018.

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