• Objective: To evaluate the safety and plaque removal efficacy of an advanced rotating-oscillating power toothbrush relative to a
sonic toothbrush with either a standard or compact brush head.
• Methodology: Two studies used a randomized, examiner-blind, two-treatment, crossover design. In Study 1, subjects were instructed
to use their first randomly assigned toothbrush for five to seven days and then, after abstaining from all oral hygiene for 24 hours,
were assessed with the Rustogi, et al. Modified Navy Plaque Index. They then brushed for two minutes and post-brushing plaque
scores were recorded. Subjects were assigned to the alternate toothbrush and the procedures were repeated. In Study 2, subjects al-
ternated using both brushes for approximately 10 days, then had four study visits three to four days apart (some variability based
on patient scheduling). In Study 1, Oral-B®Triumph™with a FlossAction™brush head and Sonicare®Elite®7300 with a full-size,
standard head were compared in a two-treatment, two-period crossover study. Study 2 compared Oral-B Triumph with a Floss Action
brush head and Sonicare Elite 7300 with a compact head in a two-treatment, four-period crossover study.
• Results: Fifty subjects completed Study 1 and 48 completed Study 2. All brushes were found to be safe and significantly reduced
plaque after a single brushing. In Study 1, Oral-B Triumph was statistically significantly (p < 0.001) more effective in plaque removal
than Sonicare Elite 7300 with the full-size brush head: whole mouth = 24% better, marginal = 31% better, approximal = 21% better.
In Study 2, Oral-B Triumph was statistically significantly (p < 0.001) more effective than Sonicare Elite 7300 with the compact
brush head: whole mouth = 12.2% better, marginal = 14.6% better, approximal = 12% better.
• Conclusion: Oral-B Triumph with its rotation-oscillation action was significantly more effective in single-use plaque removal than
Sonicare Elite 7300 with its side-to-side sonic action when fitted with either a standard or a compact brush head.
(J Clin Dent 18:00–00, 2007)
Clinical Evaluations of Plaque Removal Efficacy: An Advanced
Rotating-Oscillating Power Toothbrush versus a Sonic Toothbrush
Aaron R. Biesbrock, DMD, PhD, MS Robert D. Bartizek, MS
Patricia A. Walters, RDH, MSDH, MSOB Paul R Warren, LDS
Procter & Gamble Company
Mason, OH, USA
MaryAnn Cugini, RDH, MHP
The Forsyth Institute
Boston, MA, USA
C.R. Goyal, DDS J. Qaqish
BioSci Research Canada, Ltd
Mississauga, Ontario, Canada
Effective removal of dental plaque is crucial for the control of
numerous conditions, such as dental caries, gingivitis, and for the
prevention of progressive periodontal disease.1-4 Regular manual
tooth brushing to facilitate the mechanical removal of plaque, can
result in satisfactory plaque control. However, to be effective,
tooth brushing must be carried out using proper technique and for
a sufficient duration, typically two minutes per brushing. Un-
fortunately a large proportion of the general population fails to
carry out these measures effectively, resulting in a high incidence
of plaque-induced gingivitis.5
One development aimed at addressing this problem is the in-
troduction of the power toothbrush. A large number of models
are currently available and they differ widely in brush head
design, filament pattern, speed, and type of motion. If oral
hygiene is to be enhanced, it is important to determine which of
these toothbrushes offer consistent benefits over manual brush-
ing, and which of the many varieties of power toothbrushes are
most effective. One of the most popular power toothbrushes was
originally developed by Oral-B and used a rotation-oscillation
action with a small circular brush head. Short- and long-term
studies have shown that this brush is significantly more effective
than manual brushing.6,7A further technical advance was the
introduction of a pulsating movement in the direction of the long
axis of the filaments. This was combined with the rotation-
oscillation action of the brush head in the Oral-B®3D and 3D
Excel models, now known as the Oral-B®ProfessionalCare®
Series (Procter & Gamble, Cincinnati, OH, USA).8,9Systematic
reviews of the relative benefits of a wide range of power tooth-
brushes and of manual brushing conclude that only brushes with
rotation-oscillation action are consistently more effective than
manual brushing in reducing plaque and gingivitis in both the
short and the long term.10,11
The most recent model to be introduced in the Oral-B Pro-
fessionalCare Series is Oral-B®TriumphäProfessionalCare 9000
(Procter & Gamble, Cincinnati, OH, USA) which incorporates
advances in the earlier models within the series, including increased
oscillations and pulsations.12The development of advanced-
2The Journal of Clinical DentistryVol. XVIII, No. 4
Oral-B Triumph was used in both studies and was compared
with the Sonicare Elite using the standard brush head in Study
1 and the compact brush head in Study 2. Colgate Cavity Pro-
tection (Colgate-Palmolive, New York, NY, USA) toothpaste
was used in Study 1 and Crest Cavity Protection (Procter &
Gamble, Cincinnati, OH, USA) in Study 2.
Both studies used an examiner-blind, randomized crossover
design to examine the efficacy and safety of the two power tooth-
brushes in the removal of plaque after a period of home use.
Study 1 used a two-treatment, two-period (AB/BA) crossover de-
sign. For Study 2 a two-treatment, four-period design was adopted
with the following treatment sequences: AABB/ABBA/BBAA/
BAAB. This four-period, four-sequence design was selected for
Study 2 because it is the optimal four-period design for estimat-
ing treatment effects and carryover effects.14 Whole mouth plaque
was measured by RMNPI on all tooth areas (A-I; Figure 2) on
both buccal and lingual surfaces of the entire dentition, using a
score of 0 = absent or 1 = present. Surfaces were disclosed using
Chrom-O-Red®erythrosin FD&C red 3 solution (Germiphene
Corp., Bradford, Ontario, Canada) to stain for presence of plaque.
Subjects swished with 20 drops of solution for 15 seconds,
expectorated, rinsed with 10 ml of tap water for 10 seconds, and
expectorated. The total number of tooth areas with plaque present was
divided by the total number of tooth areas scored to calculate the
mean RMNPI score for each subject (Figure 2). Subjects’ RM-
NPI scores were calculated on a whole mouth basis (areas A-I),
along the gingival margin (areas A, B, C), and interproximally
(areas D and F). Plaque examinations were performed by a trained,
experienced dentist who had previously demonstrated the ability
to differentiate treatment effects.15
Eligible subjects, as determined at the first post-baseline visit,
were randomized to two treatment sequences in Study 1 and
four sequences in Study 2, as detailed above. At the baseline visit,
an oral hard and soft tissue examination, together with a medical
history review, was conducted and recorded. In Study 1, subjects
design power toothbrushes that deliver superior plaque removal
should involve comparative testing with existing marketed tooth-
brushes. The present studies reported in this paper were therefore
undertaken to assess the safety and plaque removal efficacy of
Oral-B Triumph with the FlossActionäbrush head, designed
with soft, flexible MicroPulseäbristles to increase approximal
penetration and improve plaque removal, versus a sonic power
toothbrush with side-to-side action (Sonicare®Elite®7300,
Philips Oral Healthcare, Inc., Snoqualmie, WA, USA) using
either a full-size (standard) or a compact brush head.
Materials and Methods
Fifty subjects in generally good health were recruited in Study
1 and 49 in Study 2 (subject populations were distinct). All sub-
jects were power toothbrush users who reported brushing their
teeth at least once a day. For inclusion in Study 1, subjects
needed to have 18 natural teeth and 16 for Study 2, with facial
and lingual surfaces which were gradable using the refinement
of the Rustogi, et alModified Navy Plaque Index (RMNPI)13and
also a whole mouth pre-brushing plaque score of ≥ 0.6 as
assessed at the first post-baseline visit. Subjects were excluded
from either study on the grounds of neglected dental health or if
they had orthodontic appliances or removable partial dentures.
Also excluded were subjects receiving active treatment for perio -
dontitis or with any disease or condition that could be expected
to interfere with the examination procedures or the subject safely
concluding the study. Continuance criteria included removal
from the study if subjects had any elective dentistry or if they
used any oral care products other than the assigned study prod-
ucts during the study. Written informed consent was obtained
from each subject before study entry, and the protocol was ap-
proved by an institutional review board before study initiation.
The toothbrushes used in these studies were:
• Oral-B Triumph (Figure 1A). This power brush has a round
brush head and a three-dimensional motion (rotation-
oscillation plus pulsation). It operates at 8,800 oscillations/
40,000 pulsations per minute. The toothbrush was fitted
with a FlossAction brush head.
• Sonicare Elite 7300. This power brush has a conventionally
shaped brush head and a side-to-side motion. It operates at
a frequency of 260 Hz. The Easy-Start feature was deacti-
vated prior to use and the brush was used on the normal set-
ting. This toothbrush can be used with either the standard,
full size brush head (Figure 1B; Study 1) or a newly de-
signed compact brush head intended for smaller mouths
and precision cleaning (Figure 1C; Study 2).
Figure 1. Brush heads: (A) Oral-B Triumph—FlossAction brush head; (B)
Sonicare Elite—full-size head; (C) Sonicare Elite—compact head.
Figure 2. Rustogi, et al. Modification of the Navy Plaque Index.13 Disclosed
plaque is scored in each tooth area as present (scored as 1) or absent (scored as
0) and recorded for both buccal and lingual surfaces. Whole mouth = areas A,
B, C, D, E, F, G, H, and I; Marginal (gumline) = areas A, B and C; Interproxi-
mal (approximal) = D and F.
Vol. XVIII, No. 4The Journal of Clinical Dentistry3
were given their first randomly assigned toothbrush and standard
dentifrice, and provided with written manufacturer’s usage in-
structions. They were asked to use these products twice each day
and to put aside all other oral hygiene products for the duration
of the study. Subjects used brushes for approximately one week
prior to examinations. They were reminded to abstain from all
oral hygiene for 24 hours prior to that visit, to refrain from eat-
ing and smoking in the previous four hours, and to bring their
toothbrush with them.
At the next visit, subjects received assessments of all soft and
hard oral tissues. The RMNPI was then assessed and all subjects
with a mean pre-brushing plaque score of ≥ 0.6 were enrolled in
the study. Qualified subjects brushed for two minutes with the
brush they had used since the first visit, in the absence of mir-
rors and out of the view of the clinical investigator. Enough
toothpaste was provided to cover the brush head. After brushing,
teeth were again disclosed and plaque was evaluated. Subjects
were given the next toothbrush and instructed again to brush
twice daily, not use any other oral hygiene products, and to re -
turn in approximately seven days for the next visit. They were
also reminded to abstain from all oral hygiene for 24 hours prior
to that visit, to refrain from eating and smoking in the previous
four hours, and to bring their toothbrush with them. The
procedure was the same at the next visit, after which Study 1
In Study 2, subjects were given both study toothbrushes (with
written usage instructions) and standard dentifrice at the baseline
visit. They were asked to alternate the use of the two tooth-
brushes for two-day periods over approximately 10 days prior to
their first plaque examination. The same oral hygiene abstention
and examination procedures were used as in Study 1. Study 2
continued for a further three visits (four post-baseline visits in
all), with washout periods of three to four days between visits.
The variable washout periods depended upon the subjects’ sched-
ules. Subjects used their normal at-home toothbrush and denti-
frice during these washout periods. At the final visit in both
studies, an oral safety assessment was conducted and any treat-
ment-related adverse events were recorded. The same clinician,
who was blind to treatment assignment, examined all subjects
throughout each study.
The primary analysis variable was the pre-brushing minus
post-brushing reduction in whole mouth RMNPI score. The re-
ductions in scores for the marginal and approximal areas were
secondary analysis variables. Analysis of variance (ANOVA)
was used to compare treatment groups for baseline RMNPI
scores and reductions in RMNPI scores. For each variable, an ini-
tial analysis was performed to test for the presence of differen-
tial carryover effects between the treatment groups. In Study 2,
if evidence of differential carryover effects was found, the treat-
ment comparison was performed using an ANOVA model with
terms for subjects, treatment groups, study periods, and carryover
effects. If no carryover effects were detected, the treatment com-
parison was performed using a model without the carryover ef-
fects term. Within-treatment analyses of RMNPI reductions were
performed using t-tests. All statistical tests were two-sided and
used a significance level of ? = 0.05.
All fifty subjects enrolled in Study 1 completed the study.
Forty-nine subjects were enrolled in Study 2, of whom one vol-
untarily withdrew at Visit 3 due to scheduling problems. No
subject withdrew from either study because of adverse effects re-
lated to treatment. Table I displays the demographic information
for both studies.
In both studies, the treatment groups were well balanced and
there were no significant differences in pre-brushing RMNPI
scores. In both studies, both brushes showed statistically signif-
icant reductions in RMNPI scores from pre-brushing to post-
brushing (all p < 0.001).
For each study, a preliminary analysis of RMNPI reductions
was performed to test for differential carryover effects between
the two treatment groups. In Study 1, no statistically significant
differential carryover effect was detected (p ≥ 0.322). In Study
2, no statistically significant differential carryover effects were
detected for whole mouth (p = 0.315) or approximal (p = 0.497)
reductions in RMNPI scores. For marginal reductions, this test
yielded p = 0.082, thus the comparison of treatments was per-
formed using an ANOVA with carryover in the model. Since the
four-period design was used, the treatment comparison was valid
even though carryover effects were present.
Comparison of the changes from pre- to post-brushing RMPI
scores between treatment groups are presented in Table II and
Figures 3 and 4. These results show that statistically significantly
(p < 0.001) more plaque was removed with Oral-B Triumph than
with the Sonicare Elite using the standard head (Study 1). This
was true for the whole mouth scores (24% better), and also for the
marginal (31% better) and approximal (21% better) areas. Simi-
larly, in Study 2, where the compact head was used with the
Sonicare Elite handle, the advantage to Oral-B Triumph was sta-
tistically significant (p < 0.001) for the whole mouth (12.2% bet-
ter), marginal (14.6% better), and approximal (12% better) scores.
In neither study was there any report of any treatment-related
adverse effects, and all oral safety examination findings were normal.
A wide range of power toothbrushes are now available with var -
iations in brush head design, mode of action, and filament pattern.
Results from the present studies show that both Sonicare Elite, with
either a standard or compact head, and Oral-B Triumph were safe
and effective in removing plaque from whole mouth, marginal, and
approximal surfaces. In both studies, Oral-B Triumph was statis-
tically significantly more effective than Sonicare Elite with respect
to all three measurements. In particular, plaque removal in the
hard-to-reach approximal regions was 21% better than for
Sonicare Elite with the standard head, and 12% better than for
(n = 50)
(n = 48)
Mean Age (Range): Years
4The Journal of Clinical DentistryVol. XVIII, No. 4
Sonicare Elite with the compact head. The superiority of Oral-
B Triumph over Sonicare Elite with both brush heads reflects an
advantage of the rotation-oscillation action over the side-to-side
action. Furthermore, these findings confirm the efficacy of the
Oral-B FlossAction brush head in plaque removal. Previous com-
parisons of Oral-B power toothbrushes with rotation-oscillation
action and Sonicare toothbrushes with side-to-side motion have
found similar advantages for the Oral-B brushes.16-18Compre-
hensive surveys of the literature comparing the efficacy of power
and manual toothbrushes have also concluded that only those
power brushes with a rotation-oscillation action are reliably su-
perior to manual brushing in removing plaque.10,11 The relation-
ship between supragingival plaque removal in one- to three-
month studies and long-term disease (e.g., caries, periodontal
disease) has not been clearly established.
The present studies were conducted according to fundamen-
tally different clinical designs. The earlier study of the two was
a two-treatment, two-period crossover design where each on-site
plaque evaluation was preceded by one-week’s usage of the
toothbrush to be tested on-site. There was no formal washout
period between uses of the test toothbrushes. A general weakness
in designs of this type is that they are vulnerable to the presence
of carryover effects which would require drastic changes to the
statistical analysis. Fortunately, carryover effects were not found
in the analysis of this study. The more recent study was a two-
treatment, four-period crossover design. In this study, subjects
used both toothbrushes at home prior to their first on-site test.
The four on-site evaluations were separated by washout periods
where subjects used their usual at-home toothbrush and tooth-
paste. The design of this more recent study allowed valid treat-
Pre-Brushing RMNPI and Post-Brushing Plaque Reduction for Studies 1 and 2
(Mean ± SD)
Post-Brushing Plaque Reduction
(Mean ± SD)% Plaque Reduction
Study 1 (N = 50)
Whole mouth A = Sonicare Elite
B = Oral-B Triumph
0.6275 ± 0.03
0.6244 ± 0.03
0.4362 ± 0.06
0.5420 ± 0.03
B 24% greater than A p < 0.001
Marginal A = Sonicare Elite
B = Oral-B Triumph
1.000 ± 0.00
1.000 ± 0.00
0.6323 ± 0.12
0.8275 ± 0.07
B 31% greater than A p < 0.001
ApproximalA = Sonicare Elite
B = Oral-B Triumph
1.000 ± 0.00
1.000 ± 0.00
0.7662 ± 0.11
0.9252 ± 0.06
B 21% greater than A p < 0.001
Study 2 (N = 48) (Adjusted Mean ± SE)
Whole mouthA = Sonicare Elite
B = Oral-B Triumph
0.620 ± 0.029
0.618 ± 0.028
0.448 ± 0.004
0.503 ± 0.004
B 12.2% greater than A p < 0.001
Marginal A = Sonicare Elite
B = Oral-B Triumph
1.000 ± 0.001
1.000 ± 0.001
0.662 ± 0.007
0.758 ± 0.007
B 14.6% greater than A p < 0.001
Approximal A = Sonicare Elite
B = Oral-B Triumph
1.000 ± 0.002
1.000 ± 0.002
0.794 ± 0.007
0.890 ± 0.007
B 12.0% greater than A p < 0.001
SD = standard deviation.
SE = standard error from crossover ANOVA.
Figure 3. Study 1—Percent plaque reduction
Figure 4. Study 2—Percent plaque reduction.
Vol. XVIII, No. 4The Journal of Clinical Dentistry5
ment comparisons to be performed whether or not carryover ef-
fects were evident. In fact, some evidence of carryover effects for
plaque reduction along the gingival margin was detected in the
study (p = 0.082).
Although the findings reported here are based on plaque re-
moval in a single-use situation, there is evidence that such short-
term effects translate into long-term benefits in oral hygiene
and, in particular, in the control of gingivitis. Rosema, et al.19 car-
ried out a study in which gingivitis was induced by not brushing
for three weeks; this was followed by four weeks of regular
brushing with either an Oral-B ProfessionalCare or a Sonicare
Elite power toothbrush. For both plaque removal and, more im-
portantly, the long-term improvement of the gingival condition, the
Oral-B brush was significantly more effective. A similar study by
Van der Weijden, et al. also reported better efficacy of Oral-B than
Sonicare power toothbrushes in the resolution of gingivitis.20It
appears, therefore, that the benefits found in short-term trials such
as those reported here can be expected to result in longer-term
gains in oral health; however longer-term comparisons with
Oral-B Triumph are needed to confirm this conclusion.
Modern toothbrush design has resulted in important, clinically
proven benefits in the control of plaque and of gingivitis.12,15,17,21,22
Despite these improvements, the prevalence of periodontal prob-
lems in the general population remains high5as compliance with
the recommendations of dental professionals is marginal, par-
ticularly with regard to the two-minute brushing time.23-25 If the
full benefits of improved toothbrush design are to be realized, it
is essential that home-use compliance is improved, and it may
well be that the greatest future improvements in oral health will
derive from devices that increase compliance. Advances in tech-
nology can greatly expand the opportunities for improving com-
pliance, such as by providing immediate visual feedback during
tooth brushing; such feedback is known to be effective in mod-
ifying behavior.26,27A number of power toothbrushes, including
some in the Oral-B range, have incorporated two minute timers,
but these have been mounted in the handle where they do not give
immediate visual feedback. The new Oral-B Triumph with
SmartGuide™ uses wireless technology to provide a remote
display which can be placed on the counter, or anywhere within
10–15 feet of the user. This device gives immediate visual feed-
back for total brushing time and quadrant time; it also has a sig-
nal that lights up if too much pressure is being applied.28This en-
hancement offers unique opportunities for increasing compliance.
The Oral-B Triumph rotating-oscillating power toothbrush
was significantly more effective in plaque removal after a single
use than the Sonicare Elite brush, with either the standard or com-
pact head. This advantage was clear not only on whole mouth
surfaces, but also on approximal surfaces which are hard to
Acknowledgments: The authors thank Danielle Siebert for data analysis and
Dr. Jane Mitchell for writing assistance. This study was supported by The Procter
& Gamble Company.
For further correspondence with the author(s) of this paper,
contact Dr. Aaron R. Biesbrock—email@example.com.
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