CE Course 4
Automated Oral Hygiene Self-Care Devices: Making Evidence-based Choices to Improve Client Outcomes
Credit: Continuing Education Hours: 2
If you have specific questions about the CE requirements in your state, or if you're not sure if the course will be accepted, please consult your state dental board.
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Table of Contents
- Course Goals
- Learning Outcomes
- Evidence-Based Methodology
- Power Toothbrushes
- Bleeding Reduction
- Outcome Measures Commonly Used in Self-Care Product Studies
- Periodontal Disease Maintenance
- Power Flossers
- Plaque and Gingivitis Reductions
- Periodontal Maintenance
- Subgingival Tips
- Special Needs Patients
- Practice Implications
- About the Author
- Supplemental Activities
- Suggested Reading
- Key Terms
- Definition of Terms
The purpose of this continuing education course is to review the evidence on automated over-the-counter oral hygiene self-care devices, discuss the outcomes and implications of the research, and evaluate the potential of selected automated self-care devices for improving client outcomes.
Upon completion of this course, the learner will be able to:
- Explain the philosophy and practice implications of utilizing evidence-based care
- Understand basic research terminology including clinical indices
- Evaluate research results for clinical relevance
- Describe the potential clinical outcomes of different automated self-care devices in:
- Plaque removal
- Reduction of gingivitis and bleeding
- Reduction of probing depth
- Reduction of periodontal pathogens
- Reduction of cytokines
- Discuss the benefits of automated self-care devices to special needs clients
- Describe how automated self-care devices affect client compliance and motivation
- Identify which clients would bene-fit from each particular device
Assessment Method: Post-test only
Dental hygienists have historically been the primary promoters of health, prevention, and wellness in dental practice. With the large number of automated self-care devices available, many clients expect their dental hygienists to be experts and advisors on such purchases. It is vitally important for dental hygienists to understand and evaluate the available clinical research findings, and along with their clients, apply them in a collaborative decision making process.
The purpose of this course is for dental hygienists to learn the scientific and practical implications of evidence-based care in the selection of automated oral hygiene self-care devices. Measurable clinical outcomes in plaque removal, reduction in gingivitis, bleeding, probing depth, periodontal pathogens, and the role of inflammatory mediators will be discussed. Automated self-care products currently available will be identified. Successful completion of the course objectives will be assessed by a post-test, to be completed by the learner after reading the article in its entirety.
Two hours of continuing education course credit will be awarded following successful completion of the post test.
The age of technology has brought forth a myriad of automated oral hygiene self-care devices proclaiming to improve oral health. It is not unusual to find consumer and professional advertising touting statistically significant findings from clinical research. Both practitioners and clients often make recommendations and purchases based on such information. However, a statistically significant result does not always translate into a clinically relevant outcome. This course discusses the evidence-based methodology as a template for decision making and reviews popular automated self-care devices focusing on evidence, statistical significance, clinical relevance, and practical application.
Oral health practitioners make hundreds of decisions daily, which impact the health and welfare of clients. Currently, a primary factor influencing this process is prior clinical experience and intuition. Recently, dentistry has embraced evidence-based decision making, a method utilized by medicine for many years.1
Evidence-based methodology focuses on using findings from clinical research as the primary rationale for clinical decision making. Traditional skills of intuition and past experience, while not discarded, are equalized and become balanced part of clinical decision making rather than the primary factor. The goal from this method is to achieve a more standardized approach to decision making often via the development of clinical practice guidelines. Ultimately, practitioners seek improved clinical outcomes from using this methodology.
A primary component of utilizing evidence-based methodology is learning to critically appraise the relevant research literature. Research rarely can define a therapy as right or wrong. More often, it demonstrates an important effect and potential for improving client care.2 The synergism between research and experience comes into play with the practitioner identifying possible treatment considerations and making appropriate applications based on each individual’s unique, clinical situation.1
Some studies carry more weight than others—particularly randomized clinical trials as the drug, product, or therapy is tested on real subjects (in-vivo) as opposed to a laboratory setting (in-vitro).2 This is particularly important for automated self-care products where the unique conditions of the oral cavity plus the dexterity and motivation of the client all play an important role in product efficacy.
One of the most significant developments in plaque removal has been the revitalization of automatic toothbrushes. Even though these products have been available for many years, it was not until the 1990s that they became a mainstay of client self-care recommendations and a primary preventive tool.
A wide selection of automated brushes is currently in the marketplace. These products vary in relation to brush head configuration and size, mechanism of action, and speed, as well as overall design. Additionally, a brush may have convenience features such as timers. Table I (PDF file) highlights automatic toothbrushes currently available at retail and Table II (PDF file) highlights main study findings.
Many studies that compare an automated toothbrush to a manual brush evaluate plaque removal.3-16 In most instances, the automated product removed more plaque than the manual. An exception is a 12-month study by Ainamo et al. that found no statistical differences between an oscillating brush and a manual control.7 In comparison, other studies showing greater plaque removal were of shorter duration ranging from four weeks to eight months.3-6,8-14,16
While plaque removal is fundamental to good oral hygiene, its significance diminishes if there is no corresponding reduction in bleeding to accompany it. Tissue that does not bleed is, in general, considered healthy and likely to remain that way.17 Bleeding, on the other hand, is strongly correlated with inflammation and consequently gingivitis.18
Several studies have evaluated the effect of automatic toothbrushes on bleeding and gingivitis. A 12- week study by Tritten and Armitage looked at the plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), clinical attachment level (CAL), gingival crevicular fluid volume (GCF), and aspartame aminoaspertate (AST) levels in the GCF. Despite greater plaque reduction— 27% vs. 17%—there were no statistical differences in any of the bleeding comparisons between a sonic brush and manual toothbrush.4 Johnson and McInnes found similar results, also between a sonic and manual brush.8
Likewise, Stolz and Bay and van der Weijden et al. demonstrated equivalency between a manual brush and an oscillating device with respect to the reduction of gingivitis.5,6
Conversely, when a brush that combines oscillations with high speed in and out pulsations was compared to a manual toothbrush, the combination brush was statistically superior at day 90 in evaluating the GI. However, while statistically significant, the differences were very small—16% vs. 12%. Additionally, the bleeding index was similar for both products.10 Ainamo et al., despite no differences in PI between an oscillating brush and a manual brush, found the oscillating device had a statistically significant greater reduction in BOP—20.5% vs. 14.6%.7
Other studies that compare different products have varying results.19,20 Isaacs et al. found statistical significance for an ultra speed oscillating brush over a sonic brush when compared via the GI. However, when comparing bleeding sites, neither product could claim superiority—12.96% vs. 15.4%.19 Grossman et al. compared an oscillating unit and a sonic device and found non significant differences in both the PI and GI.20 Recently, Heasman et al. compared two different oscillating brushes and found minimal differences between them.21 Barnes et al. discovered similar results when comparing oscillating devices.22
Outcome Measures Commonly Used in Self-Care Product Studies
Plaque Index (PI)70 (Quigley & Hein)
Assesses plaque with disclosing solution
Plaque Index (PI)71 (Turesky Modification of the Quigley-Hein PI)
Assesses plaque with disclosing solution
Plaque Index (PI)72 (Silness & Löe)
Assesses thickness of plaque at gingival margin; no disclosing solution used
Gingival Index (GI)73 (Löe & Silness)
Severity of gingivitis based on color, consistency, and bleeding on probing
Eastman Interdental Bleeding Index (EIBI)74 (Abrams, Caton, Polson, Caton, Polson)
Inflammation and bleeding in the interdental area upon tooth-pick insertion
Papilla Bleeding Index75
Bleeding on probing; interdental papilla only
Bleeding on probing (BOP)76
Bleeding after probe is gently inserted to the base of the pocket
Probing depth (PD)77
Measures the depth of the pocket, may or may not reflect bone loss
Clinical attachment Level (CAL)76
Measures level of bone from an anatomical landmark, usually the CEJ
Periodontal Disease Maintenance
There are a few studies that demonstrate the effect of automatic toothbrushes on periodontal disease parameters.3,23,24 Robinson et al. compared a sonic and oscillating brush in the areas of PI, papillary bleeding (PBS), PD, and probing attachment level (PAL). While there were no statistically significant differences in PI between the products, the sonic unit demonstrated statistical significance in reducing PBS (31.9% vs.18.1%), PD (0.84 mm vs. 0.39 mm), and PAL (0.19 mm versus -0.03 mm).23 Likewise, O’Beirne et al. studied the effect of a sonic brush on periodontal disease. Using the client as the unit of measure, the sonic brush demonstrated a significant decrease in GCF when compared to the manual (27% vs. 11%). However, there were no between group statistically significant differences in the clinical measures of PD, GI, CAL, or expression of cytokines.24 Yukna et al. evaluated a counterrotational brush with clients in supportive periodontal therapy and found superior BOP reductions compared to a manual brush.3
Special Needs Patients
Some studies have examined the use of automatic toothbrushes on clients with special needs such as those with orthodontic banding or dental implants.11-16 Ho et al. and White both studied non-compliant adolescents in orthodontic treatment. Ho et al. found a sonic brush reduced PI, BOP, PD, and gram negative bacteria better than a manual brush, while White found the sonic brush to also reduce PI and MPBI on anterior teeth.11-14 Heintze et al. compared rotary, counterrotational, and oscillating brushes to a manual brush, floss, and interdental cleaning. In this study, the rotary device removed 23% more plaque than the other brushes and 34% more plaque than a manual brush. There were no statistical differences between the products for bleeding.13 Conversely, orthodontic clients who compared automatic, counter-rotational, and rotary brushes to a manual brush demonstrated the greatest reduction in clinical parameters with the manual brush.12
Recently, Truhlar et al. completed a six-year evaluation of a counter-rotational powered toothbrush in the maintenance of implants. They found that the powered brush was significantly better at reducing the PI and GI than traditional methods.15 In a 24-week study, Wolff et al. compared a sonic and a manual brush on clients with implants. While the sonic brush significantly reduced PI and BI, it was not significantly better than the manual brush at reducing GI or PD. Importantly, though, the sonic brush was deemed safe for use on implants.16
Clearly, a general opinion can be formed that in most cases, automatic toothbrushes are better at plaque removal than a manual brush.3-6,8-16 The ability of automatic brushes to supersede a manual brush in reducing bleeding and inflammation is less clear. While automatic brushes do reduce gingivitis equivalent to manual brushing, several automated brushes have not been able to claim superiority over a manual brush or competitive product in this parameter.4,8,10,13,16,19-22 Even though Ainamo et al. found an oscillating brush to be superior in the reduction of BOP, the differences were so slight that most clinicians would have a hard time distinguishing the dif-ference.7
Lang et al. investigated preventive behaviors and found that approximately one-third of his sample population—319 adults from in and around the Detroit tri-county area—flossed daily. When observed however, only 22% of the subjects demonstrated acceptable flossing behavior.31 In this case, the results do seem to concur with the observation that people do not like to floss. The reasons vary but difficulty in manipulating the floss is often vocalized. In response to this, many different devices have been developed to make the process easier. Recently, several automated flossing devices have become available. Currently available power flossing devices are listed in Table III (PDF file) while the main outcomes from power flossing studies are in Table IV (PDF file).
Gordon et al., Cronin et al., and Isaacs et al. compared a rotating filament interdental cleaner to manual flossing in the ability to remove plaque and reduce gingivitis. The sample population included subjects with gingivitis who flossed less than once a week. In each study, the power unit was demonstrated to be as effective as floss in this demographic.32-34 Recently, Schmage et al. compared this rotating filament interdental cleaner to several different manual interproximal cleaning devices by having a dentist utilize the products on the clients once daily for a five day period. Results showed that the manual products removed a significantly greater amount of plaque than the powered unit.
Pucher et al. evaluated a high speed vibrating flosser, and found it to be equivalent to manual flossing in both dental students and clients in supportive periodontal therapy.36 Likewise, Anderson et al. and Shibly et al. studied an automated filament flossing device on plaque accumulation and gingival health and found it equivalent to manual flossing.37,38
Powered Home Irrigators
The first powered home irrigator was introduced in 1962. In the ensuing 38 years, opinions as to the effectiveness of home irrigation have varied widely in spite of the fact that the positive evidence remains consistent. Practitioners continue to confuse home irrigation outcomes with professional subgingival irrigation results. However, each therapy is a distinct and different entity with its own separate body of evidence. Table V (PDF file) highlights home irrigators currently available, and Table VI (PDF file) highlights main outcomes from home irrigation studies.
Plaque and Gingivitis Reductions
Early studies documented the effect a pulsating irrigator with a standard jet tip has on PI, calculus index (CI), and GI.43,44 In 1969, Lobene demonstrated a 50% reduction in CI and GI in clients who used a manual toothbrush and a pulsating oral irrigator compared to brushing only. Interestingly, the PI was unchanged.43 In 1971, Hoover and Robinson found that over the course of 90 days, clients who incorporated home irrigation into a routine of manual brushing and interdental stimulation with a rubber tip had significantly less calculus, plaque, and gingivitis 44 than those who did not.
More recent studies, also with a standard jet tip, concur with these results. A six-month study by Chaves compared daily 0.04% chlorhexidine (CHX) irrigation, daily water irrigation, and twice daily 0.12% CHX rinsing to a manual toothbrushing control. They found that both CHX irrigation and CHX rinsing reduced plaque by 30–35% while water irrigation had minimal effect. In spite of this, CHX irrigation, CHX rinsing, and water irrigation both showed sim-ilar significant GI reductions. Additionally, significant changes in the subgingival microflora were produced in the irrigation groups.45 Flemmig et al. conducted a six-month study with groups and methodology similar to Chaves and found concurring results.46 Newman et al. evaluated the microbiota of the clients in the study by Flemmig et al., and found that while all groups reduced the number of colony forming units (CFU) and proportion of black pigmented Bacteroides, only the 0.06% CHX daily irrigation reduced them significantly.47
In studies of shorter duration, Brownstein et al. found a 40% reduction in bleeding following 0.06% CHX irrigation compared to 26% for CHX rinsing,48 and Ciancio and co-workers compared irrigation with either an antimicrobial or placebo rinse and found both resulted in a 54–62% decrease in GI and 12% decrease in GCF.49
Other researchers have studied the benefits of home irrigation with a standard jet tip on periodontal maintenance clients.50-52 In a six-month study, Newman et al. compared water irrigation, and irrigation with zinc sulfate to a manual toothbrushing control. Results showed that clients previously treated for periodontal disease with residual bleeding and some 5 mm pockets who added water irrigation to their daily home routine of brushing and flossing, had significant reductions in GI, BOP, and PD over both the water and zinc sulfate groups; however PD reduction was minimal at 0.11 mm.50 Flemmig et al. found that periodontal maintenance clients who utilized home water irrigation had a 50% decrease in BOP over a six-month time frame compared to normal oral hygiene. MGI was also significantly reduced but PD was not.51 In a shorter inves-tigation, Walsh et al., found daily irrigation with 0.2% CHX superior to a placebo solution having a 71% greater reduction in plaque, 16% greater reduction in GBI, and a 0.55 greater reduction in PD.52
A latex-free, site-specific, low-pressure subgingival tip has been utilized in home irrigation studies on periodontitis clients.53-54 In a three-month study, Jolkovsky et al. compared home irrigation with the subgingival tip using either 0.04% CHX or water irrigation. Findings demonstrate significant reductions in GI and PD regardless of the agent used. However, the PD reduction was very small. Additionally, the concentration of 0.04% CHX irrigation significantly reduced C. rectus and black-pig-mented Bacteroides, (now Porphy-romonas and Prevotella) whereas water did not.53 In a six-week study, Fine et al. found that the subgingival tip with an antiseptic agent significantly reduced plaque, redness, BOP, and black-pigmented Bacteroides compared to a control of normal oral hygiene.54
Special Needs Clients
In clients with special needs, Felo et al. compared 0.06% CHX irrigation with the subgingival tip to 0.12% CHX rinsing on subjects with at least two implants, over a three-month period. Results showed that 0.06% CHX irrigation was superior to rinsing in terms of PI, 29% vs. 9%, MGI, 45% vs. 10%, and CI with irrigation showing a 42% decrease and rinsing a 22% increase. There were no adverse effects to the implants from the use of the device.55
A pulsating home irrigation unit which contains a small magnet has been evaluated in two research studies.56,57 Watt et al. found that water irrigation using a unit with a magnet produced a 44% greater reduction in calculus volume and 42% greater reduction in calculus area than teeth irrigated with a unit that did not have a magnet.56 Several aspects of the study have been criticized. First, only the labial and lingual aspects of anterior teeth were evaluated, and no attempt was made to separate calculus from plaque. Importantly, the index implemented is not used in the literature as a standard method for measuring plaque and calculus. In an attempt to correct these limitations, Johnson et al. conducted a 1998 study, and found a 64% statistically significant reduction in calculus with the magnetized unit. However, there were no significant reductions for plaque or gingivitis.57
Recently, a new oral irrigator that incorporates microbubbles of air into the water was introduced. In a study by Frascella et al., the device was equivalent to manual brushing in reducing plaque, gingivitis and bleeding.58
The clinical benefits of home irrigation are clear for clients with gingivitis or for those in periodontal maintenance. It is an effective means of reducing gingivitis and bleeding on probing and has the potential to reduce putative pathogens.43,55-62
The ability to significantly reduce probing depth has also been demonstrated but in most cases those reductions may be too small to be clinically relevant.50,51,53,54,62 For individuals with implants, Felo et al. showed that irrigation is both safe and effective.55
The evidence for whether or not irrigation can remove plaque is mixed, with the best results found when an antimicrobial agent was employed.43-46,48-55 However, regardless of whether or not plaque removal was enhanced by irrigation, there were still significant reduc-tions in bleeding and pathogens.43-55,62 The mechanism by which irrigation accomplishes this is still unresolved although several researchers have provided important clues. Eakle et al. and Braun and Ciancio have demonstrated the ability of irrigation to penetrate the periodontal pocket thus targeting loosely attached plaque.59,60 Importantly, Cobb et al. found that water irrigation of untreated, chronic periodontal pockets resulted in a significant qualitative change on subgingival plaque bacteria up to 6 mm.61
A recent study by Cutler et al. sheds new light on how irrigation improves the gingival health of clients with periodontitis. In addition to finding reductions in established clinical parameters such as PI, GI, BOP, and PD, home irrigation had a significant effect on GCF cytokine.62 Specifically, IL-1ß and PGE2, known mediators of inflammation that regulate the duration and severity of periodontal disease showed significant decreases after the implementation of daily home water irrigation.63-66 Additionally, IL-10, an anti-inflammatory cytokine, showed increased levels.60,64 Thus, this study indicates that home irrigation with water has the potential to selectively modulate inflammatory mediators thus reducing disease activity.62 Since inflammatory mediators such as IL-1ß and PGE2 are acknowledged as two players in the break down of bone in the periodontal disease, it seems likely that home irrigation with water could become a mandatory home care procedure for clients with or at risk for periodontal diseases.
Automated self-care devices play an important and growing role in maintaining oral health. While many practitioners conscientiously seek to recommend the best device, the evidence seems to indicate that this is not possible nor practical. Rather, the research indicates the expected potential from most products instead of the superiority of one particular brand.12,13,19,20,23,56,57 Additionally, what stands out is the inability of any one product to “do it all.” Certainly, automatic toothbrushes have the greatest abundance of research to document their plaque removing abilities,3,5,6,8-16 but home irrigation provides greater evidence in the reduction of bleeding and pathogens.44-46,48-50,52-55,62
Most automated devices are evaluated on the standard of reduction of clinical parameters such PI, BI, GI, PD, or CAL. However, recent studies by O’Beirne, et al. and Cutler, et al. demonstrate that a new benchmark may be approaching for product efficacy; the reduction of inflammatory cytokines.24,62 IL-1ß and PGE2 have been identified not only as primary agents in alveolar bone destruction, but also for the possible role they may play in heart disease and preterm low birth weight babies.63-68 Because of this, in the future, the multifunctional role that practitioners seek for product recommendations may not be one which will remove plaque and reduce gingivitis, but rather one which benefits both oral and general health.
There are many excellent, evidence- based automated self-care devices available to help clients. Due to growing client acceptance and appeal, the market is likely to continue to grow, and new brands of products will be introduced. However, it is important to keep in mind that research on one brand of product does not apply to a different brand. Each device has its own unique mechanism of action. Automatic brushes, particularly, have varying brush head configurations and sizes and powered flossers utilize different types of filaments and vibrations. It is important to look at findings from clinical research before making any product recommendations.
About the Author
Carol Jahn, RDH, MS, is the Educational Programs Manager for Waterpik Technologies. She is a nationally recognized continuing education speaker, and has written widely on oral health care topics. She has been active in ADHA serving at the national, state, and local level.
1. Visit local retailers to determine which products are available in your area. Compare availability and pricing along with travel distance from your office.
2. Visit Web sites of self-care device manufacturers or call the manu-facturer’s 800 number. Request product information on features and benefits, and copies of scientific studies supporting product usage. Find out if the company has any complementary demonstration programs that allow you to get product for viewing/inoffice demonstrations.
3. Set-up a self-care section in your office that allows clients the opportunity to touch and feel products available in your area. Compile a list of the retailers that carry the products, along with suggested pricing. Follow up with your client in a couple of weeks via phone or email to determine if they have purchased the product. Offer to have clients come in with the device if they are having in difficulties in using it. Document your actions to see if it helps to increase client compliance.
4. Attend trade shows at least once a year to learn about new products on the market.
5. Scan your journals monthly and set aside time to read articles that are relevant to the types of clients and problems you see in your practice.
6. Seek out and attend continuing education courses that provide a strong scientific foundation. Limit attendance at courses that are primarily case study or anecdotal information.
- Geyman JP, Deyo RA, Ramsey SD: Evidence-Based Clinical Practice: Concepts and Approaches. Boston, Butterworth Heinemann, 2000.
- Hamer S, Collinson G: Achieving Evidence-Based Practice: A Handbook for Practitioners. Edinburgh, Bailliere Tindall Royal College of Nursing, 1999.
- O’Hehir TE, Suvan J: Perio Reports: Compendium of Current Research. Flagstaff, Perio Reports, 1997.
- Understanding and evaluating scientific literature. OSAP Monthly Focus 1999;3:1-8.
- Page RC, et al.: Design and conduct of clinical trials of products designed for the prevention, diagnosis and therapy of periodontitis. Chicago, American Academy of Periodontology, 1995.
- Walmsley AD: The electric toothbrush: A review. Br Dent J 1997;182(6):209-218.
- Brothwell DJ, Jutai, DK, Hawkins RJ: An update of mechanical oral hygiene practices: Evidence-based recommendations for disease prevention. CDA J 1998;64(4):295-304.
- Greenstein G: Position paper: The role of supra- and subgingival irrigation in the treatment of periodontal disease. 1995. The American Academy of Periodontology, Chicago, IL.
Blinding—assignment to a study group without the subject or the investigator knowing the assignment
Control group—subjects in a group not receiving the
Efficacy—the degree to which a treatment is beneficial
when implemented under the usual conditions of an investigation, usually a randomized clinical trial
Evidenced-based care—the conscientious and judicious use of current best evidence from clinical care research in the management of individual clients
In-vitro—in laboratory setting
In-vivo—on human subjects
Randomization—the unbiased assignment of subjects to treatment groups
Randomized clinical trial— a study in which a group receiving an experimental treatment is compared with a control group receiving a placebo or standard treatment
Safety—treatment or device in which potential harm is out-weighted by therapeutic benefits
Statistical significance— whether the observed outcome from one therapy is better than a comparative
therapy, and not represented by random fluctuations