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Long‐term impact of powered toothbrush on oral health: 11‐year cohort study

Authors:

Abstract

Aims This study aimed to assess 11‐year longitudinal effects of powered toothbrush on periodontal health, caries and tooth loss in an adult population. Materials and Methods Participants of Study of Health in Pomerania (SHIP) cohort with dental examinations and interview data at SHIP‐1, SHIP‐2 or SHIP‐3 examinations were included. Mixed‐effects linear regression models were constructed between the exposure (manual versus powered toothbrush) and outcome variables (periodontal status using mean probing depth (PD) and mean clinical attachment loss (CAL), caries status using DMFS and DFS scores, and tooth loss), adjusting for potential baseline covariates. Results Final baseline (SHIP‐1) study sample comprised of 2,819 participants. Powered toothbrush users increased from 18.3% (SHIP‐1) to 36.9% (SHIP‐3); were younger; had significantly less mean PD [β: −0.09 (95% CI: −0.16; −0.02)] and mean CAL [β: −0.19 (95% CI: −0.32; −0.07)] progressions; and had 17.7% less DMFS progression and 19.5% more teeth retained than the manual toothbrushers. Conclusions In the long‐term, powered toothbrush seems to be effective in reducing mean PD and mean CAL progressions, besides increasing the number of teeth retained.
J Clin Periodontol. 2019;00:1–10.    
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wileyonlinelibrary.com/journal/jcpe
1 | INTRODUCTION
Periodontitis and caries are the most commonly occurring den-
tal diseases worldwide (Marcenes et al., 2013) and account for
about 60% of tooth loss (Glockmann, Panzner, Huhn, Sigusch, &
Glockmann, 2011). The main aetiology for both diseases is accu-
mulation of bacterial plaque on tooth surfaces (Löe, Theilade, &
Jensen, 1965; Marsh & Nyvad, 2008; Newman, 1986; Theilade,
Wright, Jensen, & Löe, 1966). It has been well established that the
cornerstone for prevention of periodontitis and caries is through
supragingival plaque control and fluoride usage, respectively.
Althou gh personal ora l hygiene methods su ch as toothbrushi ng can
prevent biofilm accumulation and gingivitis (Tonetti et al., 2015), it
has to be noted that proper brushing skills are vital to achieve this.
Effective brushing is linked to a number of influencing factors.
Usually, brushing skills are acquired through parents, and it takes
time to actually master them perfectly (Unkel, Fenton, Hobbs, &
Received:17Januar y2019 
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  Revised:26A pril2019 
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  Accepted:29April2019
DOI: 10.1111/jc pe.13126
CLINICAL PERIODONTOLOGY
Long‐term impact of powered toothbrush on oral health:
11‐year cohort study
Vinay Pitchika1| Christiane Pink1| Henry Völzke2| Alexander Welk1|
Thomas Kocher1| Birte Holtfreter1
This is an open access article under the terms of the Creat ive Commo ns Attri bution-NonCo mmercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2019 The Authors. Journal of Clinical Periodontology Published by John Wiley & Sons Ltd.
1Department of Restorative Dentistry,
Periodontology, Endodontology
and Preventive and Pediatric
Dentistry, University Medicine Greifswald,
Greifswald, Germany
2Institute of Community
Medicine, University Medicine Greifswald,
Greifswald, Germany
Correspondence
Vinay Pitchika, Unit of Periodontology,
Department of Restorative Dentistry,
Periodontology, and Endodontology
and Preventive and Pediatric Dentistry,
University Medicine Greifswald,
Fleischmannstr. 42, Greifswald 17475,
Germa ny.
Email: pitchikav@uni-greifswald.de
Funding information
The SHIP cohort study is part of the
Community Medicine Research Net (http://
www.mediz in.uni-greif swald.de/cm) of the
University of Greifswald, Germany, which is
funded by the German Federal Ministry of
Education and Research (BMBF, grant no.
01ZZ96030, 01ZZ0701); the Ministry for
Cultural Affairs and the Ministry for Social
Affairs of the Federal State of Mecklenburg-
West Pomerania (SHIP; http://www.mediz
in.uni-greif swald.de/cm). Vi.P was supported
by funding provided by Procter and Gamble
Co. towards personnel costs.
Abstract
Aims: This study aimed to assess 11-year longitudinal effects of powered toothbrush
on periodontal health, caries and tooth loss in an adult population.
Materials and Methods: Participants of Study of Health in Pomerania (SHIP) cohort
with dental examinations and interview data at SHIP-1, SHIP-2 or SHIP-3 examina-
tions were included. Mixed-effects linear regression models were constructed be-
tween the exposure (manual versus powered toothbrush) and outcome variables
(periodontal status using mean probing depth (PD) and mean clinical attachment loss
(CAL), caries status using DMFS and DFS scores, and tooth loss), adjusting for poten-
tial baseline covariates.
Results: Final baseline (SHIP-1) study sample comprised of 2,819 participants.
Powered toothbrush users increased from 18.3% (SHIP-1) to 36.9% (SHIP-3); were
younger; had significantly less mean PD [β:−0.09(95%CI:−0.16;−0.02)]andmean
CAL [β: −0.19(95%CI:−0.32; −0.07)]progressions;and had 17.7% less DMFS pro-
gression and 19.5% more teeth retained than the manual toothbrushers.
Conclusions: In the long-term, powered toothbrush seems to be effective in reduc-
ing mean PD and mean CAL progressions, besides increasing the number of teeth
retained.
KEYWORDS
caries, gingivitis, oral hygiene, periodontitis, tooth loss, toothbrush
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Frere, 1995). If an improper technique is detected at a later point
of life, it is difficult to modify it (Alcouffe, 1988). Furthermore,
the fine motor skills might degrade with ageing and could impair
maintaining proper oral hygiene in elderly people (Felder, Reveal,
Lemon, & Brown, 1994; Hitz Lindenmüller & Lambrecht, 2011).
Powered toothbrushes (PTB) are advertised as having better
biofilm removal capacity than manual toothbrushes (Verma & Bhat,
2004), which was attested by in vitro studies (Hunt, 2002; Schmidt,
Zaugg, Weiger, & Walter, 2013). Under clinical settings, they were ef-
fective in removing plaque (Rosema, Slot, van Palenstein Helderman,
Wiggelinkhuizen, & Van der Weijden, 2016) and tackling gingivitis
(Yaacob et al., 2014). However, studies assessing the long-term ef-
fectiveness of PTBs on slowing initiation or progression of periodon-
titis are limited (Dentino et al., 2002; Dörfer, Staehle, & Wolff, 2016;
Moritis, Jenkins, Hefti, Schmitt, & McGrady, 2008; Schmalz et al., 2017;
Wilson, Levine, Dequincey, & Killoy, 1993); these studies mainly fo-
cussed on plaque, calculus or gingivitis. In addition to having employed
small sample sizes (maximum of 180 subjects) and short follow-up
times ranging from few weeks to a maximum of 3 years, these studies
did not include tooth loss as an outcome, which is of paramount im-
portance for patients. A recently published Cochrane review concluded
“Powered toothbrushes reduce plaque and gingivitis more than manual
toothbrushing in the short and long term. The clinical importance of
these findings remains unclear” (Yaacob et al., 2014). Similarly, stud-
ies associating PTB usage with caries are limited (Papas et al., 2007;
Willershausen & Watermann, 2001). Furthermore, prospective pop-
ulation-based cohort studies assessing the effectiveness of PTBs are
unavailable as of now.
Therefore, in this study, we aimed to estimate the longitudinal
effects of PTB usage on (a) periodontal health in terms of mean
probing depths (PD) and mean clinical attachment loss (CAL), (b)
coronal caries experience using decayed, missing and filled surfaces
(DMFS) and decayed and filled surfaces (DFS) scores and (c) number
of teeth present using 11-year data from the representative popula-
tion-based cohort, Study of Health in Pomerania (SHIP).
2 | MATERIAL AND METHODS
2.1 | Study population
The study sample was obtained from the ongoing prospective cohort
study (SHIP), which adapted a two-stage cluster design (Keil et al.,
1988). The cohort was initiated in 1997–2001 (SHIP-0) and was fol-
lowed up after 5 (SHIP-1), 11 (SHIP-2) and 16 years (SHIP-3) (Völzke
et al., 2011). Since information about the PTB usage was not avail-
able in SHIP-0, we considered the data from SHIP-1 as baseline ex-
amination and SHIP-2 and SHIP-3 as the 6- and 11-year follow-ups,
respectively. Participants with information on exposure, outcomes
and covariates within at least one examination were included in the
study. The study started with a sample of 3,300 participants at base-
line. The flow of study participants in the study is shown in Figure 1.
The study protocol was approved a priori by the ethics committee of
the University of Greifswald, and written informed consent for the
interviews, clinical and dental examinations was obtained from all the
participants.
2.2 | Dental examination
Dental examinations were performed by calibrated and licensed
dentists. Initial training was conducted by a periodontist (TK). The
intra-rater and inter-rater reliability values are shown in Table S1.
Identical recording protocols were used for all time points. From the
dental examination, number of teeth present (full mouth), PD, CAL,
DMFS score and DFS score were calculated. Detailed information on
the dental examination can be found in the supplementary material.
2.3 | Interviews and medical examination
Trained and certified interviewers conducted computer-assisted per-
sonal interviews for participants during all the visits to collect informa-
tion on the exposure and covariates. Participants were asked whether
they used powered or manual toothbrush at each time point from
SHIP-1 to SHIP-3. Based on the toothbrushing frequency, participants
werecategorisedintoirregular(<2 times/day)orregularbrushers(≥2
times/day). Classification of covariates considered in the study (educa-
tional status at the start of study, smoking status, toothbrushing fre-
quency, dental visit in the last 12 months, periodontal treatment in the
last 5 years, diabetes, physical activity and Centers for Disease Control
and Prevention/American Academy of Periodontology (CDC/AAP)
case definition of periodontitis) are mentioned in Table 1. Body mass
index (BMI) was calculated as weight in kg/(height in m)2. At baseline
(SHIP-1), known diabetic cases, defined as diagnosed cases accord-
ing to self-reported physician's diagnosis or treatment with anti-dia-
betic drugs (Anatomical Therapeutic Chemical Classification System
code A10), were recorded. Prevalent cases based on information
from SHIP-0 were combined with incident cases between SHIP-0 and
SHIP-1. Blood samples were drawn at non-fasting status to determine
HbA1c levels using HPLC method (Bio-Rad Diamat, Munich, Germany).
Clinical Relevance
Scientific rationale for the study: Powered toothbrushes
have been in the market for quite a long time and, their
effectiveness has been shown in a number of clinical or
observational studies. However, long-term effectiveness
of powered toothbrushes in a population-based study has
never been performed.
Principal findings: Powered toothbrush users had reduced
progression of probing depths and clinical attachment loss.
On the long run, this has been translated into retaining
more number of teeth.
Practical implications: Powered toothbrush seems to be
an effective (preventive) tool in maintaining oral hygiene.
Therefore, dental practitioners might recommend its usage.
    
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PITCHIK A eT Al.
2.4 | Statistical analyses
All analyses were performed using Stata/SE 14.2 (StataCorp 2015,
College Station, T X, USA). The following time-varying outcomes were
considered: (a) mean PD, (b) mean CAL, (c) DMFS, (d) DFS and (e)
number of teeth present. Continuous and categorical variables were
compared using Student's t test and chi-square test, respectively. To
assess the longitudinal effects of PTB usage on different outcomes,
mixed-effects linear regression models over three time points were
constructed for each outcome using the entire sample. The time
variable was divided by 11, to obtain estimates that reflect the ef-
fect of PTB usage 11 years from baseline, which was the time span
between SHIP-1 and SHIP-3. All covariates were selected a priori,
based on the clinical knowledge. Models were constructed with sub-
ject ID and time as random intercept and slope, respectively, so that
they took into effect the repeated measurements within subjects at
different follow-ups, which denote the multiple levels. The advantage
with mixed-effects modelling approach is that it requires complete
datasets at each follow-up separately, but not across examinations.
All models were adjusted for baseline (SHIP-1) covariates, such as
age, sex, BMI, education, smoking, diabetic status, HbA1c values,
frequency of toothbrushing and history of dental visit in the last
12 months. Physical activity was included as additional covariate in
the number of teeth present models. Mean PD and CAL models were
additionally adjusted for physical activity and history of periodontal
treatments during the past 5 years; but the random slope was ex-
cluded as the models did not converge. Age was included in the model
as a restricted cubic spline with three knots. The adjusted estimates
(β), 95 confidence intervals (95% CI) and their corresponding p-values
were calculated. After obtaining the adjusted estimates, percentage
change for MTB and PTB users after 11 years of follow-up time was
calculated using the formula ((βPTBβMTB)/βMTB)*100 (United States
FIGURE 1 Overview of the flow of
study participants in the study
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Census Bureau, 2015). p-Values < 0.05 were considered as indicator
of statistical significance.
Analyses were restricted to the following subsets: (a) regular
brushers (n = 2,464 at SHIP-1), (b) younger subjects (25–55 years,
n = 1,617) and (c) younger regular brushers (n = 1,403). After ini-
tial analyses, participants were stratified based on the CDC/AAP
case definition of periodontitis to observe if the severity of peri-
odontal disease had an influence on the association with PTB, and
all models were repeated. Furthermore, sensitivity analyses were
performed on the entire sample models by including subjective
influence on oral hygiene, inter-dental aids usage, screening for
preventive medicine and cancer or preventive dental screening
(Table S5). Additionally, to avoid over-adjustment, we performed
directed acyclic graphs (DAGs) for each outcome spectrum
(periodontitis, caries and no. of teeth present) (Textor, Hardt,
& Knüppel, 2011). DAGs for each outcome resulted in adjusting
for age, sex, education, toothbrushing frequency, dental visit in
the last 12 months and history of periodontal treatment within
the last 5 years (Figure S1). Thereafter, models were constructed
adjusting for these variables under each outcome. The recom-
mendations of the Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) guidelines for observational
studies were applied for reporting (von Elm et al., 2014).
3 | RESULTS
3.1 | Baseline characteristics
A total of 2,819 participants with mean age of 52.1 ± 14.4 years were
included in the model (Table 1). PTB users were younger (46.3 years)
than the MTB users (53.4 years). PTB users fared well in education,
toothbrushing frequency, dental visit in the last 12 months, diabetic
TABLE 1 Baseline characteristics (SHIP 1) for participants present in the final model
Variable Group Tot al MTB user PTB user p‐value
Sample size for SHIP 1 in model 2,819 2,304 515
Age (in years) 52.1 ± 14.4 53.4 ± 14. 5 46.3 ± 12.4 <0.001**
Sex Male 1,353 (48.0) 1,156 (50.2) 197 (38.3) <0.001*
Female 1,466 (52.0) 1,14 8 (49. 8) 318 (61.7 )
Education <10 years 868 (30.8) 788 (34.2) 80 (15.5) <0.001*
10 years 1,408 (50.0) 1,10 3 (47.9) 305 (59.2)
>10 ye ars 543 (19.2 ) 413 (17.9) 130 (25.3)
Smoking status Non-smoker 1,207 (42.8) 999 (43.4) 208 (40.4) 0.36*
Former smoker 870 (30.9) 710 (30.8) 160 (31.1)
Occasional smoker 97 (3.4) 74 (3.2) 23 (4.4)
Current smoker 645 (22.9) 521 (22.6) 124 (24.1)
Toothbrushing frequency Irregular brushers 442 (15.7) 391 (17.0) 51 (9.9) <0.001*
Regular brushers 2,377 (84.3) 1,913 (83.0) 464 (90.1)
Dental visit in the last 12 months No 20 0 (7. 1) 176 ( 7.6) 24 (4.6) 0.02*
Yes 2,619 (92 .9) 2,128 (92.4) 491 (95.4)
Periodontal treatment in the last
5 years
No 2, 513 (89. 2) 2,076 (90.1) 437 (85.0) 0.002*
Yes 304 (10.8) 227 (9.9) 77 (15.0)
Diabetes No 2,568 (91.1) 2,090 (90.7) 478 (92.8) 0.13*
Yes 251 (8.9) 214 ( 9.3) 37 (7. 2)
HbA1c (in %) - 5.4 ± 0.8 5.4 ± 0.8 5.2 ± 0.8 <0.001**
BMI (in kg/m2) - 27.8 ± 4.8 27.9 ± 4.8 27. 0 ± 4.9 <0.001**
Physical activity <1 hr sport/week 1,784 (63.3) 1,510 (65. 6) 274 (5 3. 2) <0.001*
1–2 hr sport/week 490 (17.4) 381 (16.5) 109 (21.2)
>2 hr sport/week 545 (19. 3) 413 (17.9) 132 (25.6)
CDC/AAP case definition No/mild periodontitis 1,187 (48 .3) 885 (44.7) 302 (63.2) <0.001*
Moderate periodontitis 877 (35.7) 740 (37.3) 137 (28.7)
Severe periodontitis 395 (16.0) 356 (18.0) 39 (8.1)
Note: Data are presented as mean ± standard deviation or number (column percentages).
Abbreviations: MTB: manual toothbrush; PTB: powered toothbrush; BMI: body mass index; CDC/AAP: Centers for Disease Control and Prevention/
American Academy of Periodontology.
*p-Values were obtained using chi-square test for categorical variables. **p-Values were obtained using Student's t test for continuous variables.
Bold numbers indicate statistically significant effect (p-Value < 0.05).
    
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PITCHIK A eT Al.
status, BMI and physical activity. PTB usage in our study had increased
over time [SHIP-1: 515 (18.3%); SHIP-2: 540 (27.3%); SHIP-3: 543
(36.9 %)].Comp ar edto MT Bu ser s, PT Bu ser sh ad lo we rm ea nP D,me an
CAL, DMFS and DFS scores while having more teeth present (Table 2).
3.2 | Association between PTB usage and
periodontal measures
After adjustment, PTB usage was significantly associated with re-
duced mean PD and mean CAL progression in the entire sample as
well as all subsets (Table 3). “PTB usage” denotes the effect of PTB
usage on dependent variable for time = 0 (baseline/SHIP-1). Time
(per 11-year increase) reflects the rate of change in MTB users over
11-year follow-up (SHIP-3). Interaction denotes exposure-depend-
ent (PTB vs. MTB) difference in the rates of change over 11-year
follow-up period. For example, in the entire sample, PTB users
had −0.0 3 mm smaller mean PD th an MTB brushers at ba seline.
However, after 11 years, MTB users had 0.41 mm of mean PD pro-
gression, while the PTB users had 0.09 mm significantly less mean
PD, that is 0.32 mm mean PD progression. This difference could also
be translated as PTB users having 22% less mean PD progression
over a period of 11 years (Figure 2 and Table S2). On exploring the
subsets of study participants, PTB users had a significantly low mean
PDprogressions(estimates rangingfrom −0.09to −0.11).Similarly,
PTB usage was associated with low mean CAL progression in the en-
tiresample[−0.19(−0.32;−0.07)]aswellasinallsubsets(estimates
ranging f rom −0.19 to −0.26). On s tratif ying the stu dy populat ion
based on the CDC/AAP definition (Table 4 and Figure 2), PTB usage
in the entire sample and regular brushers was associated with less
mean PD progression among subjects with no/mild and moderate
periodontitis, and less mean CAL progression in subjects with mod-
erate periodontitis only. Subjects with severe periodontitis did not
benefit from the usage of PTB.
3.3 | Association between PTB usage and caries
With respect to caries, PTB users had lower DMFS and DFS scores
throughout the study period (Table 2). On further exploring the data
after adjustment (Table 3), PTB users in the entire sample and in the
regular brushers’ subset had 1.32 surfaces (half-mouth) less DMFS
progression, corresponding to 17.7% significantly less DMFS pro-
gression than the MTB users; but this association was not present
among other subsets of participants. PTB usage had no influence on
the DFS scores (Table 3), even after stratifying the subjects based on
CDC/AAP definition (Table S3).
3.4 | Association between PTB usage and
number of teeth present
PTB users also had significantly less number of teeth lost over 11-year
follow-up, indirectly leading to more number of teeth present (Table 2).
After adjustment, reduction in the number of teeth present was about
Outcome Examination (N)
Mean ± SD
Tot al MTB user PTB user p‐Valuea
Mean PD SHIP-1 (2,616) 2.31 ± 0.71 2.34 ± 0.76 2.13 ± 0.57 <0.001
SHIP-2 (1,847) 2.64 ± 0.58 2.69 ± 0:60 2.52 ± 0:51 <0.001
SHIP-3 (1,372) 2.49 ± 0.59 2.55 ± 0.65 2.38 ± 0.45 <0.001
Mean CAL SHIP-1 (2,482) 2.23 ± 1.72 2.38 ± 1.78 1.62 ± 1.31 <0.001
SHIP-2 (1,758) 2.85 ± 1.53 3.02 ± 1.62 2.44 ± 1.20 <0.001
SHIP-3 (1,294) 2.54 ± 1.45 2.76 ± 1.59 2.21 ± 1.13 <0.001
DMFS SHIP-1 (2,787) 33.1 ± 16.4 34.1 ± 16.7 28.6 ± 14.3 <0.001
SHIP-2 (1,925) 34.6 ± 15.8 36.0 ± 16.2 30.8 ± 14.0 <0.001
SHIP-3 (1,417) 36.0 ± 15.8 38.1 ± 16.4 32.6 ± 14.3 <0.001
DFS SHIP-1 (2,709) 32.5 ± 16.2 33.4 ± 16.5 28.6 ± 14.3 <0.001
SHIP-2 (1,902) 34.3 ± 15.7 35.8 ± 16.2 30.7 ± 14.0 <0.001
SHIP-3 (1,417) 36.0 ± 15.8 38.1 ± 16.4 32.6 ± 14.3 <0.001
No. of teeth
present
SHIP-1 (2,819) 19.9 ± 7.5 19.2 ± 7.8 23.1 ± 5.0 <0.001
SHIP-2 (1,975) 20.0 ± 7.6 18.9 ± 8.1 22.9 ± 4.9 <0.001
SHIP-3 (1,471) 20.1 ± 7.6 18.5 ± 8.4 22.8 ± 5.0 <0.001
Note: Data are presented as mean ± standard deviation.
Abbreviations: MTB: manual toothbrush; PTB: powered toothbrush; PD: probing depth, CAL: clini-
cal attachment loss, DMFS: decayed, missing, filled surfaces; DFS: decayed, filled sur faces.
ap-Values were obtained using Student's t test.
Bold numbers indicate statistically significant differences (p < 0.05). Mean values do not allow
directly comparing the time course of the variables, since the three follow-ups are not identical in
terms of included SHIP participants.
TABLE 2 Distribution of dental
variables in participants included in the
models, stratified by examination time
points
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20% lesser in PTB users, that is PTB users retained on average 0.36
teeth more than their counterparts. Regularly brushing PTB users re-
tained 0.39 teeth more. On analysing the strata of study sample based
on CDC/AAP definition categories, PTB users in the entire sample with
no/mild periodontitis had 0.19 more teeth retained (Table S4).
4 | DISCUSSION
This study assessed the longitudinal association of PTB usage on peri-
odontit is, caries and num ber of teeth present f rom a prospective p opu-
lation-based cohort. Our main findings suggest that PTB usage over a
period of 11 year s had an effect i n reducing the pro gression of mean PD
and mean CAL in the study participants. This protective effect trans-
lated into more retained teeth in the whole cohort over the 11-year
study period. However, PTB usage did not influence caries (DFS) pro-
gression. These data circumvent the critique of the latest Cochrane re-
view on this subject: Empirical data on thresholds for clinically important
differences in plaque and gingivitis levels would help to determine whether
oral hygiene aids provide important health benefits (Yaacob et al., 2014).
Published short-term studies on PTB usage showed better plaque con-
trol and reduced gingivitis, but the present longitudinal study showed
for the first time that these effects are likely to get translated into re-
duced progression of PD and CAL. Also, more retained teeth speak in
favour of a clear tangible health benefit of PTB.
The main strength of the present study is that prospective data
from a population-based cohort with a follow-up time of 11 years
have been analysed. Our study had the benefit of extensive dental
data in terms of surface-level periodontal measures and caries data.
We identified and adjusted for commonly observed covariates such
as age, sex, BMI, education, smoking, diabetic status, HbA1c values,
toothbrushing frequency and history of dental visits, in addition to
periodontal treatment history and physical activity in some models.
Our study also had its share of limitations. It might be argued that
PTB users were younger in age, with better education, and oral health
awareness, in addition to having better physical activity. However, the
associations observed in this study were not lost even after adjusting
for all the relevant factors, although residual confounding cannot be
excluded. Furthermore, when the entire sample models were addi-
tionally adjusted for subjective influence on oral hygiene, inter-dental
TABLE 3 Results from mixed-effects linear models evaluating the effects of powered toothbrush usage on rates of change in oral health
parameters
Outcome Variable
β (95% CI)
Entire sample Regular brushers Younger subjects
Younger regular
brushers
Mean PDaPTB usage −0.03(−0.08;0.03) −0.03(−0.09;0.03) −0.02(−0.09;0.04) −0.02(−0.08;0.05)
Time (per 11-year increase) 0.41 (0.38; 0.45) 0.42 (0.38; 0.46) 0.42 (0.38; 0.47) 0.43 (0.39; 0.48)
Interaction −0.09 (−0.16; −0.02) −0.10 (−0.17; −0.02) −0.09 (−0.17; −0.01) −0.11 (−0.19; −0.02)
Mean CALaPTB usage 0.00(−0.11;0.11) −0.01(−0.13;0.10) 0.02(−0.10;0.14) 0.03(−0.10;0.15)
Time (per 11-year increase) 0.93 (0.86; 0.99) 0.93 (0.85; 1.00) 0.99 (0.91; 1.07) 1.00 (0.92; 1.09)
Interaction −0.19 (−0.32; −0.07) 0.19 (−0.33; −0.06) −0.23 (−0.38; −0.09) 0.26 (−0.41; −0.11)
DMFSbPTB usage 0.06(−0.67;0.79) 0.07(−0.69;0.83) 0.11(−0.69;0.92) 0.26(−0. 59;1.12)
Time (per 11-year increase) 7.4 3 (6 .97; 7. 89) 7. 51 ( 7.01 ; 8. 01) 6.84 (6.26; 7.42) 6.93 (6.30; 7.56)
Interaction −1. 32 (−2.18; −0.45) −1. 32 (−2.23; −0.41) 0.73(−1.71;0.25) −0.78(−1.82;0.25)
DFSbPTB usage 0.41(−0.01;0.82) 0.37(−0.06;0.80) 0.35(−0.14;0.85) 0.36(−0.16;0.87)
Time (per 11-year increase) 3.68 (3.41; 3.94) 3.60 (3.32; 3.87) 3.78 (3.44; 4.13) 3.71 (3.34; 4.08)
Interaction −0.40(−0.89;0.10) −0.25(−0.76;0.26) 0.40(−0.99;0. 20) −0.29(−0.90;0.33)
No. of teeth
presentb
PTB usage −0.03(−0.24;0.18) −0.03(−0.25;0.19) 0.00(−0. 21;0.21) 0.05(−0.27;0.17)
Time (per 11-year increase) 1.86(−2.01;−1.72) −1.88(−2.03;−1.72) −1.38(−1.56;−1.21) 1.39(−1.58;−1.20)
Interaction 0.36 (0.11; 0.62) 0.39 (0.12; 0.66) 0.01(−0.25;0.27) 0.04(−0.23;0.31)
Note: All models were adjusted for baseline covariates, such as, age, sex, education, smoking, BMI, diabetic status, HbA1c values, toothbrushing fre-
quency and dental visits in the last 12 months. Subject ID and time were constructed as random intercept and slope, respectively. Number of teeth
present models were additionally adjusted for physical activity. Mean PD and mean CAL models were additionally adjusted for physical activity and
periodontal treatment within the last 5 years.
PTB usage: Effects of powered toothbrush usage on dependent variable for time = 0 (baseline/SHIP-1). Time (per 11-year increase): Rate of change
for manual toothbrush user over 11-year follow-up period. Interaction: Exposure-dependent (PTB versus MTB) difference in the rates of change over
11-year follow-up period.
Abbreviations: β: beta coefficient; 95% CI: 95% confidence interval; PD: probing depth; CAL: clinical attachment loss; DMFS: decayed, missing, filled
surfaces; DFS: decayed, filled surfaces.
aModels were performed without the inclusion of random slope.
bModels were performed with the inclusion of time per 11-year increase as a random slope.
Bold numbers indicate statistically significant effect (p-Value < 0.05).
    
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 7
PITCHIK A eT Al.
aids usage, screening for preventive medicine and cancer or preven-
tive dental screening, none of these variables failed to elicit significant
effect on the estimates. To avoid over-adjustment, based on the infor-
mation from DAGs, models were adjusted only for age, sex, education,
toothbrushing frequency, dental visits in the last 12 months and his-
tory of periodontal treatment within the last 5 years. This conserva-
tive approach did not alter any of our results (Table S6).
Periodontal and caries examinations were recorded using half-
mouth basis, which might not reflect the absolute values, although
it has less bias in comparison with full-mouth method (Tran et al.,
2016). Furthermore, caries was recorded only on cavitation level.
Leaving out non-cavitated caries lesions would have under-repre-
sented the caries burden in this study. Information on PTB usage
was obtained only through a simple question with binomial answer
possibility. In addition to usage of PTB in combination with MTB,
differentiation between different types of PTB, that is oscillatory
vs. vibratory, battery-powered vs. electric, sonic vs. ultra-sonic,
was not measured, especially when there were studies reporting
differences among them (Deacon et al., 2010; Rosema et al., 2016).
However, the differences between the different types of PTB
are not well studied, and more focus in this direction is needed.
Because it is not plausible to perform a long-term randomized con-
trolled trial to test the effectiveness of PTBs over MTBs, evidence
from well-designed population-based cohorts/practice-based re-
search is relevant for the dental community.
Although the effectiveness of PTB on periodontitis has been
well documented in the literature (Forrest & Miller, 2004; de Jager,
Rmaile, Darch, & Bikker, 2017; Yaacob et al., 2014), the evidence
arriving from long-term studies is limited (Ainamo, Xie, Ainamo, &
Kallio, 1997; Dentino et al., 2002; Dörfer, Joerss, & Wolff, 2009;
Dörfer et al., 2016). In a 12-month longitudinal study, Ainamo et al.
(1997) found PTBs to be effective in controlling gingivitis in terms of
reducing bleeding on probing, but they were not significantly bet-
ter in removing plaque. Dörfer et al. (2016) performed a random-
ized study with the longest follow-up time of 3 years, in which they
did not find any significant differences in PD and CAL progression
between PTB and MTB users with pre-existing recessions >2 mm.
However, as shown in a recent meta-analysis (Yaacob et al., 2014),
the use of a PTB results in less supragingival plaque, which in con-
sequence prevents or decreases the magnitude of gingivitis. An im-
proved oral hygiene has an effect on preventing the transition from
gingivitis to periodontitis rather than the progression of periodontitis
(Hellström, Ramberg, Krok, & Lindhe, 1996; Ramseier et al., 2017;
Schätzle et al., 2004). In line with this observation, we could see that
PTB had a distinct effect in reducing the PD and CAL progression in
subjects affected with no/mild or moderate periodontitis, whereas
the subjects with severe periodontitis did not benefit from the better
oral hygiene through PTB usage (Hellström et al., 1996). Although
the magnitude of change in PD and CAL among subjects with severe
periodontitis was in line with the moderate periodontitis subjects,
the effects were not significant, presumably due to the reduced sam-
ple size. Furthermore, it could be observed that the mean age of the
PTB users was significantly lower than the MTB users. In addition to
oral hygiene, progression of the periodontal disease in elderly people
is influenced by many other factors (Lamster, 2016), which might not
be counteracted by toothbrushing alone. Ramseier et al. (2017) con-
cluded from the 40-year results of the Sri Lanka study that gingivitis
control in young subjects is essential in preventing progression of
FIGURE 2 Percentage differences between the rates of change for powered toothbrush users in comparison with manual toothbrush
users. (a) Percentage change for powdered toothbrush users in entire sample and different subsets (regular brushers, younger subjects and
younger regular brushers) analysed. (b) Percentage change for powdered toothbrush users in entire sample stratified based on the CDC/AAP
definition of periodontitis (No/mild, moderate and severe)
8 
|
   PITCHIKA eT Al .
periodontitis, further loss of attachment and ultimately tooth loss.
Our data may be interpreted that subjects using a PTB experience
less attachment loss, which after 11-year follow-up resulted on av-
erage 0.36 more teeth than the MTB users. Furthermore, subjects
with no/mild periodontitis had 0.19 more teeth retained than their
MTB counterparts.
To our knowledge, the number of studies assessing the rela-
tionship between caries and PTB is rare. In an interventional study
among drug-induced xerostomia patients (N = 80) with a follow-up
time of 1 year, Papas et al. (2007) recorded a significant reduction of
root caries among PTB users. Willershausen and Watermann (2001)
performed an interventional study (N = 40) with a 3-year follow-up
on elementary school children, but did not observe any benefit of
PTB on caries prevalence. A systematic review conducted on seven
studies assessing influence of oral hygiene in the absence of fluo-
ride on dental caries concluded “Personal oral hygiene in the ab-
sence of fluorides has failed to show a benefit in terms of reducing
the incidence of dental caries” (Hujoel, Hujoel, & Kotsakis, 2018).
In line with this argumentation, lack of association between PTB
usage and DFS seems plausible. However, PTB usage was associ-
ated with less DMFS progression, and this was due to the influence
from the M-component, which is a predominant feature in the el-
derly population.
There has been a significant association of PTB usage with more
number of teeth retained in the entire sample and in the regular
brushers’ subset. Based on this, it is evident that the PTB usage on the
long run helps in preventing tooth loss and maintaining the number
of teeth in the oral cavity. From this study, it could be seen that the
TABLE 4 Results from mixed-effects linear models evaluating the effects of powered toothbrush usage on rates of change in
periodontitis models stratified by CDC/AAP definition
Outcome Variable
β (95% CI)
Entire sample Regular brushers Younger subjects
Younger regular
brushers
CDC/AAP definition = no/mild periodontitis
Mean PDaPTB usage −0.00(−0.05;0.04) 0.01(−0.04;0.06) 0.01(−0.11;0.13) 0.03(−0.09;0.16)
Time (per 11-year increase) 0.42 (0.38; 0.45) 0.43 (0.39; 0.47) 0.37 (0.30; 0.45) 0.40 (0.32; 0.48)
Interaction −0.06 (−0.13; −0.00) −0.08 (−0.14; −0.01) −0.05(−0.22;0.12) −0.08(−0.26;0.10)
Mean CALaPTB usage −0.02(−0.11;0.07) 0.01(−0.09;0.10) 0.06(−0.21;0.33) 0.10(−0.19;0.39)
Time (per 11-year increase) 0.82 (0.75; 0.89) 0.83 (0.75; 0.91) 0.67 (0.50; 0.83) 0.73 (0.55; 0.92)
Interaction −0.07(−0.19;0.06) −0.09(−0.22;0.04) −0.09(−0.47;0.29) −0.15(−0.55;0.25)
CDC/AAP definition = moderate periodontitis
Mean PDaPTB usage 0.04(−0.04;0.13) 0.05(−0.04;0.14) −0.04(−0.17,0.09) −0.05(−0.18;0.09)
Time (per 11-year increase) 0.27 (0.22; 0.33) 0.28(−0.22;0.34) 0.29 (0.21; 0.36) 0.28 (0.20; 0.37)
Interaction −0.16 (−0.27; −0.05) −0.17 (−0.29; −0.05) −0.04(−0.21;0.13) −0.05(−0.23;0.13)
Mean CALaPTB usage 0.04(−0.12;0.21) 0.03(−0.14;0.20) 0.00(−0.25;0.25) −0.04(−0.30;0. 22)
Time (per 11-year increase) 0.64 (0.55; 0.74) 0.65 (0.55; 0.76) 0.63 (0.50; 0.76) 0.61 (0.47; 0.75)
Interaction −0.32 (0. 51; −0.12) −0.33 (−0.54; − 0.13) −0.17(−0.46;0.12) −0.17(−0.48;0.14)
CDC/AAP definition = severe periodontitis
Mean PDaPTB usage −0.0 0(−0.23;0.23) −0.03(−0. 28;0.22) 0.10(−0.24;0.45) − 0.01(−0.38;0.36)
Time (per 11-year increase) 0.36 (0.23, 0.49) 0.36 (0.22; 0.51) 0.41 (0.24; 0.58) 0.40 (0.22; 0.59)
Interaction −0.22(−0.52;0.08) −0.19(−0.52;0.13) −0.45(−0.93;0.03) −0.31(−0.81;0.19)
Mean CALaPTB usage −0.09(−0. 50;0.32) −0.06(−0.48;0.37) −0.21(−0.85;0.43) −0.27(−0.92;0.37)
Time (per 11-year increase) 1.13 (0.92; 1.35) 1.12 (0.89; 1.35) 1.09 (0.80; 1.38) 1.06 (0.76; 1.35)
Interaction −0.30(−0.81;0.21) −0.35(−0.88;0.18) −0.65(−1.50;0. 20) −0. 59(−1.40;0.22)
Note: All models were adjusted for baseline covariates, such as, age, sex, education, smoking, BMI, diabetic status, HbA1c values, toothbrushing
frequency, dental visit in the last 12 months, physical activity and history of periodontal treatment in the last 5 years. Subject ID was constructed as
random intercept.
Abbreviations: β: beta coefficient; 95% CI: 95% confidence interval. CDC/AAP: Centers for Disease Control and Prevention/American Academy of
Periodontology. PD: probing depth; CAL: clinical attachment loss; DMFS: decayed, missing, filled surfaces; DFS: decayed, filled surfaces. PTB usage:
Effects of powered toothbrush usage on dependent variable for time = 0 (baseline/SHIP-1). Time (per 11-year increase): Rate of change for manual
toothbrush user over 11-year follow-up period. Interaction: Exposure-dependent (PTB versus MTB) dif ference in the rates of change over 11-year
follow-up period.
aModels were performed without the inclusion of random slope.
Bold numbers indicate statistically significant effect (p-Value < 0.05).
    
|
 9
PITCHIK A eT Al.
PTB usage may have a long-term protective effect on the oral health
in general. It could also be seen that there has been a gradual increase
in the usage of PTB over time. The reasons for this might be increased
advertisements and dentist recommendations. German Oral Health
Study showed that recently there has been an increase in the usage of
inter-dental cleaning aids (Jordan & Micheelis, 2016). This, in addition
to increased PTB usage as observed in the SHIP cohort, reflects the
increased awareness of German population towards oral hygiene.
5 | CONCLUSION
From the results in this study, it could be seen that the PTB usage
has a long-term protective effect on the oral health in terms of re-
duced probing depths, clinical attachments and number of teeth los t.
Based on this, it seems that the PTB usage in the long run helps in
maintaining the number of teeth in the oral cavity and reducing the
progression of periodontal disease burden.
ACKNOWLEDGEMENTS
The authors thank the study participants and all contributions to the
SHIP data collection by dental and medical examiners, technicians,
interviewers and assistants.
CONFLICTS OF INTERESTS
Prof. Dr. Thomas Kocher had received grants from Procter and
Gamble Co. to pay the salary for a scientist for 6 months, which did
not have any influence on the study design, data analysis and inter-
pretation of the results. The authors declare no potential conflicts of
interest with respect to the authorship and publication of this article,
and this includes financial interests.
ORCID
Vinay Pitchika https://orcid.org/0000-0001-6947-2602
Christiane Pink https://orcid.org/0000-0001-5950-2716
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Additional supporting information may be found online in the
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How to cite this article: Pitchika V, Pink C, Völzke H, Welk A,
Kocher T, Holtfreter B. Long-term impact of powered
toothbrush on oral health: 11-year cohort study. J Clin
Periodontol. 2019;00:1–10. https ://doi.org/10.1111/
jcpe.13126
... Several studies have shown that tooth loss is associated with various risk factors, but there is no consensus on 15 which factor is the most relevant (Müller et al., 2017). Recently, we confirmed the effectiveness of powered toothbrushes (PTB) through a longitudinal study design (Pitchika et al., 2019). Furthermore, we assessed the long-term benefits of PTB and interdental cleaning aid (IDA) use on tooth retention on a population level through a repeated cross-sectional study design using Oaxaca decomposition models (Pitchika et al., 2021). ...
... Another possibility could be that education improves decision-making ability. For example, there is a strong correlation between education and PTB or IDA use, as well as dental visits for screening purposes (Pitchika et al., 2019, Pitchika et al., 2021. Although these factors have a positive impact on 25 the outcome beyond education, having a better education makes people better able to make informed decisions, leading to an indirect effect on tooth loss. ...
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Aim: This study aimed to identify the factors influencing the changes in the number of teeth present, and the number of healthy or filled surfaces between two time-points. Materials and methods: Repeated cross-sectional data from population-based studies, i.e., the German Oral Health Studies (DMS-III vs DMS-V), the Studies of Health in Pomerania (SHIP-START-0 vs. SHIP-TREND-0), and the Jönköping study (2003 vs. 2013), were analysed. Oaxaca decomposition models were constructed for the outcomes (number of teeth, number of healthy surfaces and number of filled surfaces). Results: The number of teeth increased between examinations [DMS: +2.26 (adults), +4.92 (seniors), SHIP: +1.67, Jönköping: +0.96]. Improvements in education and dental awareness brought a positive change in all outcomes. An increase in powered toothbrushing and interdental cleaning showed a great impact in DMS (adults: +0.25 tooth, +0.78 healthy surface, +0.38 filled surface; seniors: +1.19 teeth, 5.79 healthy surfaces, +0.48 filled surface). Interdental cleaning decreased by 4% between SHIP-START-0 and SHIP-TREND-0, which negatively affected the outcomes. Conclusion: From this study, it can be concluded that education may be the most important factor having a direct and indirect effect on the outcomes. However, for better oral health, powered toothbrushing and interdental cleaning should not be neglected.
... erefore, it is highly important for nurses to have adequate knowledge about the correct brushing method and also toothbrush maintenance, replacement, and cleaning [9][10][11][12]. If the toothbrush is not properly maintained and used, it can cause oral infections and diseases [9][10][11][12][13][14][15]. Changing the toothbrush every 2.5-6 months and brushing for two minutes or more twice a day are some correct methods of toothbrush use [13,[16][17][18][19][20][21][22]. ...
... If the toothbrush is not properly maintained and used, it can cause oral infections and diseases [9][10][11][12][13][14][15]. Changing the toothbrush every 2.5-6 months and brushing for two minutes or more twice a day are some correct methods of toothbrush use [13,[16][17][18][19][20][21][22]. ...
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Background: Since nurses are considered a role model in society, they should have sufficient knowledge, attitude, and practice in the field of oral hygiene. This study was aimed to assess the nurses' knowledge, practice, and attitude towards toothbrush maintenance and use. Methods: In this cross-sectional study, 325 nurses working in hospitals affiliated to Kermanshah University of Medical Sciences were randomly recruited. Data collection tools included a demographic information form and a researcher-made questionnaire on knowledge, attitude, and practice regarding toothbrush maintenance and use. Data were analyzed by SPSS software using descriptive and inferential statistics (Mann-Whitney U and Kruskal-Wallis H). Results: The mean scores of nurses' knowledge, attitude, and practice were 59.2 ± 16.4, 64.2 ± 20.6, and 51.4 ± 17.0 out of 100, respectively. There was no statistically significant relation between nurses' knowledge, attitude, and practice and their gender, age, level of education, and work experience. Conclusions: Nurses had moderate knowledge, attitude, and practice regarding toothbrush maintenance and use, which is not very desirable given their role model. Therefore, training courses are recommended to be held to increase the nurses' knowledge, attitude, and practice regarding toothbrush maintenance and use.
... These standard toothbrushes are widely considered essential for oral health care. If dental plaque, mainly bacterial biofilm, is not properly controlled by toothbrushing, it may cause gingivitis and dental caries, and in severe cases, periodontitis and tooth loss [1][2][3][4][5]. To ensure proper oral hygiene, the mechanical action of toothbrushing is the most common method used for plaque removal [6,7]. ...
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Non-carious cervical lesions (NCCLs) are saucer-shaped abrasions of a tooth. NCCLs can form due to various etiologies, including toothbrushing wear, acid erosion, and mechanical stress. Owing to this complex interplay, the mechanism of NCCLs in tooth abrasion has not been established. This study aims to develop a numerical method using a computational toothbrush to simulate NCCLs. The forces acting on the teeth and the amount of abrasion generated were evaluated. The discrete element method using in-house code, connected particle model, and Archard wear model were applied for brushing. In the toothbrush model, 42 acrylic tufts were fixed into a toothbrush head. The teeth models with enamel properties comprised four flat plates and two grooves to simulate the anterior teeth and NCCLs. The brushing speed and depth for one cycle were established as simulation parameters. The force applied within the ununiform plane was concentrated on several bristles as the toothbrush passed through the interproximal space. The brushing force (depth) had a greater effect on tooth abrasion than the brushing speed. Toothbrushing abrasion was mainly concentrated in the interproximal space. Therefore, forceful tooth brushing can cause NCCLs from the interproximal space to the cervical area of the tooth.
... health of hard dental tissues, because it increases the risk of secondary caries formation. 43,44 Restorations that are manufactured with CAD-CAM technology are milled with rotary instruments coated with diamond abrasive particles of 64-mm grit size. 45 The above instruments produce a rather high initial surface roughness, which may lead to the increased wear of adjacent teeth and the discoloration of the restoration. ...
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Purpose: The aim of this in vitro study was to examine the effect of Er,Cr:YSGG laser-assisted tooth bleaching treatment on the elution of monomers and surface roughness of a hybrid computer-aided design-computer-aided manufacturing (CAD-CAM) material, and to compare it with a resin composite for direct restorations. Methods and materials: Forty specimens of a hybrid CAD-CAM material (Enamic) and forty of a conventional resin composite (Tetric) were fabricated and randomly divided into four groups (n=10). Half of the specimens of each material were stored in distilled water and the other half in artificial saliva for 7 days. At the end of this period, the storage medium was analyzed by high-performance liquid chromatography (HPLC), and the surface roughness parameters of the specimens were evaluated by optical imaging noncontact interferometric profilometry. Afterwards, half of the specimens of each tested material received a conventional in-office tooth bleaching treatment and the other half an Er,Cr:YSGG laser-assisted bleaching treatment, and then they were again incubated in distilled water and artificial saliva for an additional 7-day time period. At the end of this period, the effect of the bleaching treatments on elution of monomers and surface roughness of the tested materials was evaluated. Results: Bisphenol A (BPA), urethane dimethacrylate (UDMA), triethylene glycol dimethacrylate (TEGDMA), and bisphenol A-glycidyl dimethacrylate (BisGMA) were eluted from the conventional resin composite into both the solutions tested. Only TEGDMA was eluted from the hybrid CAD-CAM material. However, no statistically significant differences were found among the surface roughness parameters of both materials. Both the conventional and Er,Cr:YSGG laser-assisted tooth bleaching treatments affected the monomer elution from the composite resin. However, there were no statistically significant differences (p<0.05) between the treatments. Conclusions: According to the results of this study, tooth bleaching with Er,Cr:YSGG laser or conventional technique is safe, even if the bleaching agent comes in contact with hybrid CAD-CAM restorations.
... The present findings align with those on oral health benefits of electric toothbrush use, 8,9,17,19,43 as well as observations from long-term obser-r r vational studies in which electric toothbrush users showed less gingival disease than manual toothbrush users. [22][23][24]30 Another potential limitation of this work is that the sample may be biased with regard to demographic variables such as age and income. Younger consumers and those with higher socioeconomic status might be over-represented in the sample. ...
Article
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Purpose: To determine if an interactive electric toothbrush and smartphone application (app) can reduce self-reported gingival bleeding and promote better brushing behaviour based on global, in-market usage data. Materials and methods: Anonymised data were collected worldwide between July 2020 and January 2021 from users of interactive oscillating-rotating electric toothbrushes and app (Oral-B Genius, GeniusX and iO). Self-reported gingival bleeding and brushing behaviour data captured via the app were sent to Google Firebase and Google BigQuery to aid processing and analysis. Results: Data from 16.7 million brushing sessions were analysed. 439,481 new users responded at least once to the app question: 'Do you have gum bleeding?' Of users answering the question over their first two weeks of app use (153,201), the proportion reporting bleeding decreased statistically significantly from week 1 to 2 (28.8% to 17.1%, p < 0.0001). Of users answering the question over each of the first five weeks (43,060) a further statistically significant decrease in those reporting bleeding was seen in each consecutive week, with the week-5 rate being 12.7% (p < 0.0001 vs any previous week). Decreases in duration of excessive pressure (i.e. > 2.5 N - 3.0 N depending on the handle) decreased the proportion of self-reported gingival bleeding (p < 0.0001). Users brushed longer and with less overpressure (p < 0.0001) with vs without live feedback from the app, and showed 94.4% average coverage with live feedback. Conclusion: The interactive oscillating-rotating electric toothbrushes and app, particularly with live feedback, promote good brushing behaviour. Self-reported gingival bleeding occurred less frequently the longer the system was used.
... A point-of-care (POC) device, based on noninvasive biomarkers, such as identified in the present study, may open a new avenue for such periodontal home care. If patients were able to screen themselves for periodontitis, they could initiate self-treatment, because incipient and moderate periodontitis can be halted or at least retarded by improved oral home care measures [74]. ...
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Background Periodontitis is among the most common chronic diseases worldwide, and it is one of the main reasons for tooth loss. Comprehensive profiling of the metabolite content of the saliva can enable the identification of novel pathways associated with periodontitis and highlight non-invasive markers to facilitate time and cost-effective screening efforts for the presence of periodontitis and the prediction of tooth loss. Methods We first investigated cross-sectional associations of 13 oral health variables with saliva levels of 562 metabolites, measured by untargeted mass spectrometry among a sub-sample ( n = 938) of the Study of Health in Pomerania (SHIP-2) using linear regression models adjusting for common confounders. We took forward any candidate metabolite associated with at least two oral variables, to test for an association with a 5-year tooth loss over and above baseline oral health status using negative binomial regression models. Results We identified 84 saliva metabolites that were associated with at least one oral variable cross-sectionally, for a subset of which we observed robust replication in an independent study. Out of 34 metabolites associated with more than two oral variables, baseline saliva levels of nine metabolites were positively associated with a 5-year tooth loss. Across all analyses, the metabolites 2-pyrrolidineacetic acid and butyrylputrescine were the most consistent candidate metabolites, likely reflecting oral dysbiosis. Other candidate metabolites likely reflected tissue destruction and cell proliferation. Conclusions Untargeted metabolic profiling of saliva replicated metabolic signatures of periodontal status and revealed novel metabolites associated with periodontitis and future tooth loss.
... Toothbrushes can be manual but the mastery of brushing techniques is essential to have an optimal action against dental plaque. On the other hand, electric toothbrushes allow you to eliminate plaque without mastering the technique [98,99]. Moreover, the use of electric and sonic toothbrushes has demonstrated their efficacity to reduce the incidence of inflammation [100]. ...
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Background: Pre-eclampsia, the second most frequent direct source of maternal mortality, is a multisystem gestational disorder characterized by proteinuria and maternal hypertension after the 20th gestational week. Although the causes of pre-eclampsia are still discussed, research has suggested that the placenta has a central place in the pathogenesis of this disease. Moreover, current surveys indicated that periodontal disorders observed during the pregnancy and more particularly, periodontal pathogens could be link to the risk of pre-eclampsia. Objectives: This article aims to review recent studies focusing on periodontal conditions and pathogens associated with pre-eclampsia. Methods: The process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Results: Metabolic conditions, immunological changes, fluctuating progesterone and estrogen levels of the pregnant woman induce a dysbiosis of the oral microbiota and contribute to increase inflammation of periodontal tissues. Periodontal pathogens could diffuse through the bloodstream inducing a placenta inflammatory response as well as inflammatory molecules produced in response to periodontopathogens could migrate through the bloodstream leading to a placenta inflammatory response. Also, periodontopathogens can colonize the vaginal microbiota through the gastrointestinal tract or during oro-genital contacts. Conclusion: A cumulative bi-directional relationship between periodontal conditions, pathogens and the pre-eclampsia exists.
... Außerdem stieg von DMS III zu DMS V die Anwendung von elektrischen Zahnbürsten von 14,9 % auf 48,3 % bei den 35-bis 44-Jährigen und von 7,2 % auf 36,9 % bei den 65-bis 74-Jährigen. Laut einer 11-jährigen longitudinalen Untersuchung, bei der Anwender einer elektrischen Zahnbürste eine verringerte Parodontitisprogression und eine erhöhte Zahnretention aufwiesen [36], kann man davon ausgehen, dass der Gebrauch elektrischer Zahnbürsten nicht nur dem manuell eingeschränkten Benutzer, sondern auch dem normalen Konsumenten einen Vorteil bringt. Zusammengefasst bedeutet dies, dass die Industrie und die Zahnärzte mit ihren Teams eine hervorragende deutschlandweite Aufklärungsarbeit betrieben haben, die in den letzten 17 Jahren zu einer deutlichen Verbesserung der oralen Gesundheit durch eine verbesserte Mundhygiene geführt hat. ...
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Zusammenfassung Hintergrund Zur Veränderung der oralen Krankheitslast in der deutschen Allgemeinbevölkerung über die letzten 20 Jahre gibt es bisher keine umfassende Darstellung. Fragestellung Wie haben sich die Prävalenzen der Karies, der Parodontitis und des Zahnverlustes und deren Determinanten von 1997 bis 2014 in Deutschland verändert? Material und Methoden Ausgewertet wurden Daten von 35- bis 44- und 65- bis 74-Jährigen der Deutschen Mundgesundheitsstudien (DMS) III, IV und V sowie von 25- bis 74-Jährigen der Studies of Health in Pomerania (SHIP‑0 und SHIP-Trend-0). Der Decayed, Missing, Filled Teeth Index (DMFT), die Anzahl füllungsfreier Zähne, der Community Periodontal Index (CPI) als auch Daten zur Zahnzahl und Zahnlosigkeit wurden herangezogen. Ergebnisse In beiden Studien waren bzgl. der Determinanten eine Zunahme der Probanden mit hoher Schulbildung, eine geringfügige Abnahme der Raucher sowie eine Verbesserung der Mundhygiene zu beobachten. Bei den 35- bis 44-Jährigen stieg die Anzahl gesunder Zähne von 11,9 in DMS III auf 16,8 in DMS V, während bei den Senioren die Anzahl gesunder Zähne um 5,9 anstieg. In SHIP wurde ein ähnlicher Trend beobachtet. Die Prävalenz des höchsten CPI-Grades 4 fiel in den DMS bei den 35- bis 44-Jährigen von 9,3 % auf 3,5 %; bei den Senioren lag der Wert 2014 wieder auf dem Niveau von 1997 (10,5 % und 9,8 %). Parallel dazu hat sich der Anteil der zahnlosen Senioren in beiden Studien halbiert. Die Zahnzahl nahm über alle Altersklassen hinweg zu. Diskussion DMS und SHIP zeigten über die Jahre konsistent eine Zunahme gesunder, füllungsfreier Zähne, eine geringfügige Reduktion der Probanden mit CPI-Grad 4 sowie mehr Zahnerhalt und weniger Zahnlosigkeit. Bedingt durch den höheren Zahnerhalt und die Alterung der Gesellschaft ist in Zukunft mit einer erhöhten parodontalen Behandlungslast zu rechnen.
Article
Aim This systematic review and network meta-analysis synthesizes the available clinical evidence concerning efficacy with respect to plaque scores following a brushing action with oscillating-rotating (OR) or high-frequency sonic (HFS) powered toothbrushes (PTB) compared to a manual toothbrush (MTB) as control. Material and methods Databases were searched up to April 15, 2021, for clinical trials that evaluated the efficacy of a PTB with OR or HFS technology compared to an MTB on plaque removal after a single brushing action and conducted with healthy adult patients. Meta-analysis (MA) and a network meta-analysis (NMA) were performed. Results Twenty-eight eligible publications, including 56 relevant comparisons, were retrieved. The overall NMA results for the mean post-brushing score showed a statistically significant difference for the comparison between an OR PTB and an MTB (SMD=-0.43;95%CI[-0.696;-0.171]). The change in plaque score data showed a significant effect of a PTB over an MTB and OR over HFS. Based on ranking, the OR PTB was highest, followed by the HFS PTB and the MTB. Conclusion Within the limitations of the present study design, based on the outcome following a single brushing action, it can be concluded that for dental plaque removal there is a high certainty for a small effect of a PTB over an MTB. This supports the recommendation to use a powered toothbrush for daily plaque removal. There is moderate certainty for a very small benefit for the use of a powered toothbrush with an OR over an HFS mode of action.
Article
Aims : To determine impact of oral hygiene behaviour change intervention compared to the prevailing standard of oral hygiene advice provided in general dental practice, on bleeding on probing (BOP) in gingivitis patients, over 3-months. The effect of providing power-brushes was also evaluated. Materials and Methods : NHS dental practices were cluster-randomised to intervention or control (2:1). Dentists at intervention sites received behaviour modification training. Participants were stratified to high (≥20% BOP) or low (<20% BOP) presence of gingivitis and a subset assigned a power-brush. BOP and plaque scores were assessed at baseline and 3-months. Results : A total of 538 participants (369:169; intervention: control) completed the study. BOP reduced in both gingivitis groups with significantly greater reduction in intervention compared to control group (BOP:38% vs 19%, p=0.0236); Borderline significance favouring the intervention was demonstrated for the low gingivitis group (BOP:37% vs 15%, p=0.0523). A highly significant reduction in BOP (intervention vs control) was demonstrated for volunteers who swapped from manual to power-brush (44% vs 37%, p=0.0039). Plaque score improved more in control than intervention group (Plaque:37% vs 44%, p=0.00215). Conclusions : Behaviour change techniques were readily mastered by the dental professional researchers. The introduction of an oral hygiene behaviour change intervention significantly reduced gingivitis in volunteer patients compared to control at 3 months. Swapping to a power-brush significantly favoured BOP reduction compared to manual brush continuation although plaque reduction did not follow expectation in comparison to BOP scores. Behaviour change techniques should routinely be considered in patient care. Clinical Significance : Plaque-induced gingivitis is highly prevalent in the UK despite being preventable with good oral hygiene. Its continuum, periodontitis, negative impacts quality of life. This study suggests oral hygiene behavioural interventions (GPS) significantly reduce gingivitis and that GPS introduction will improve oral health and may improve quality of life.
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Objective To conduct a systematic review of randomised trials assessing the association between personal oral hygiene and dental caries in the absence of the confounding effects of fluoride. Background Dental caries continues to affect close to 100% of the global population. There is a century‐old conflict on whether dental caries is caused by poor oral hygiene or poorly formed teeth (ie, teeth with dental defects). Resolving this conflict is of significant public health importance as these two hypotheses on dental caries aetiology can lead to different prevention strategies. Methods A systematic search for randomised trials was conducted using predefined criteria in 3 databases. The impact of personal oral hygiene interventions on coronal dental caries incidence was evaluated using random‐effects models. Results Three randomised studies involving a total of 743 participants were included. Personal oral hygiene interventions failed to influence the incidence of dental caries (Δ Decayed, Missing and Filled Surfaces (DFMS) = −0.11; 95% confidence interval: (−0.91, 0.69; P‐value < .79)) despite meticulous deplaquing of teeth. There was no significant heterogeneity in the trial results (heterogeneity chi‐squared = 1.88, P = .39). The findings were robust to sensitivity analyses, including consideration of the results of nonrandomised studies. Conclusion Personal oral hygiene in the absence of fluorides has failed to show a benefit in terms of reducing the incidence of dental caries.
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Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
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Purpose: This randomized clinical study compared the influence of manual and power toothbrushes on clinical and microbiological findings in initial treatment of periodontitis. Methods: A total of 72 participants with a mean age of 55.7 years were randomly assigned to three groups (n= 24):oscillating-rotating (OR), sonic-active (SA) and manual toothbrush (MTB). At baseline, after 4 weeks and after 12 weeks, the following parameters were assessed:modified Quigley-Hein-Index (QHI), papilla bleeding index (PBI), periodontal pocket depth (PPD), bleeding on probing (BOP) and recession. For microbiological analysis (PCR) of 11 periodontal pathogenic bacteria, samples of sulcular fluid were taken from the deepest pockets. Statistical analysis was performed using ANOVA, with the level of significance set at α= 5%. Results: All clinical parameters:PBI, modified QHI, PPD, BOP and recession showed an improvement after 12 weeks compared to baseline, regardless of which toothbrush system was used. Regarding PBI, the SA group showed significantly greater improvement compared to OR and MTB (P< 0.01). In plaque removal (QHI) only OR was significantly more effective than MTB (P= 0.01). Periodontal parameters showed a significantly higher reduction of PPD for SA compared to MTB and MTB compared to OR (Plt; 0.05), while for BOP only a significantly higher reduction in SA compared to OR was detected (P= 0.01) Microbiological analysis showed an improvement in prevalence of several bacteria without significant differences between groups. Clinical significance: Patients might benefit from powered TB systems, especially in initial treatment of periodontitis.
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We have previously demonstrated that half-mouth four-site periodontal examination protocol performed well in estimating periodontitis prevalence. This study aimed to assess biases associated with this same protocol in estimating periodontitis extent and severity in a United States population. Periodontitis extent as determined by percentage of sites with clinical attachment loss (CAL) ≥3, and ≥5 mm and severity as determined by mean CAL were calculated for full-mouth examination and half-mouth four-site protocol based on 3734 adults sampled from the National Health and Nutrition Examination Survey 2009–2010. Probing depth was excluded because of low data reliability. The comparison between full-mouth and half-mouth assessments was based on bias, relative bias, Wilcoxon signed-rank test, and intra-class correlation coefficient (ICC). For full-mouth examination, periodontitis extent was 21.2% for CAL ≥3 mm and 6.9% for CAL ≥5 mm; periodontitis severity (mean CAL) was 1.73 mm. Half-mouth four-site protocol provided bias −1.2% and relative bias −5.7% for extent (CAL ≥3 mm). Corresponding numbers were −0.3% and 4.3% for extent (CAL ≥5 mm), −0.05 mm and −2.9% for severity. Although the difference between full-mouth and half-mouth assessments was statistically significant, ICCs between them were ≥0.96 for extent (CAL ≥3, 5 mm), and severity (mean CAL). Half-mouth four-site protocol performed well in estimating periodontitis extent and severity based on CAL. Therefore, this protocol should be considered for periodontitis surveillance.
Article
Objectives: To assess long-term attachment and periodontitis-related tooth loss (PTL) in untreated periodontal disease over 40 years. Material and methods: Data originated from the natural history of periodontitis study in Sri Lankan tea labourers first examined in 1970. In 2010, 75 subjects (15.6%) of the original cohort were re-examined. Results: PTL over 40 years varied between 0 and 28 teeth (mean 13.1). Four subjects presented with no PTL while 12 were edentulous. Logistic regression revealed attachment loss as a statistically significant covariate for PTL (p<0.004). Markov chain analysis showed that smoking and calculus were associated with disease initiation and that calculus, plaque and gingivitis were associated with loss of attachment and progression to advanced disease. Mean attachment loss <1.81mm at the age of 30 yielded highest sensitivity and specificity (0.71) to allocate subjects into a cohort with a dentition of at least 20 teeth at 60 years of age. Conclusions: These results highlight the importance of treating early periodontitis along with smoking cessation, in those under 30 years of age. They further show that calculus removal, plaque control and the control of gingivitis are essential in preventing disease progression, further loss of attachment and ultimately tooth loss. This article is protected by copyright. All rights reserved.
Article
Objective: Evaluate the short-term clinical efficacy of high-frequency, high-amplitude sonic powered toothbrushes compared to manual toothbrushes on plaque removal and gingivitis reduction in everyday use through a meta-analysis of randomized controlled trials. Methods: Embase, MEDLINE, BIOSIS, Inspec, PQ SciTech, Compendex, SciSearch and IADR abstracts databases were searched. Eligible were clinical trials comparing at least one manual to one sonic powered toothbrush on plaque or gingivitis reduction over four weeks to three months in subjects without disability that could affect tooth brushing. Two authors selected and extracted data from eligible studies. When insufficient information was available, researchers were contacted. Data were pooled using random-effects models to compute standardized mean differences (SMD) and 95% confidence intervals (95% CI) quantifying differences in plaque or gingivitis reduction. Risk for bias and sources of heterogeneity were assessed. Results:The combined results of 18 studies comprising 1,870 subjects showed that sonic powered toothbrushes had statistically significantly greater plaque removal (SMD = -0.89, 95%CI = [-1.27, -0.51]) and gingivitis reduction (-0.67, [-1.01, -0.32]). Heterogeneity was large and bias was not apparent. Conclusion:High-frequency, high-amplitude sonic powered toothbrushes decreased plaque and gingivitis significantly more effectively than manual toothbrushes in everyday use in studies lasting up to three months.
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Background The Institute of German Dentists (IDZ) carried out the First German Oral Health Study (DMS I) in 1989 laying the foundations for ongoing socio-epidemiological moni-toring of oral health and dental care in Germany. This survey’s new fifth edition (DMS V) delivers updated oral epidemiology data for 2014, which has been collected in accordance with international standards for epidemiological research. Study design DMS V is a cross-sectional socio-epidemiological study with a study population rep-resentative of the population as a whole. It collects key oral health and dental care indicators across four age cohorts and places this data in relevant sociodemographic and behavioural context. Key results Children (aged 12) 81 % of children were caries-free. The mean extent of caries experience (measured using the DMFT index) was 0.5 teeth. Gingivitis was present in 78 % of the children examined. This represents a consistency in the robust and continuous caries decline in children observed since the 1980s. Younger adults (aged 35 to 44) Almost all younger adults had caries experience. The mean DMFT score in this cohort was 11.2 teeth. 52 % of younger adults had periodontal disease (measured using the CDC/AAP case definition). Edentulism in younger adults was virtually nonexis-tent. A sustained reduction in caries experience is evident in younger adults and accompanied by a reduction in the level of severe periodontal disease. This is noteworthy, as the younger adults are the first age cohort for whom individual prophylaxis was available during childhood and adolescence. Younger elderly (aged 65 to 74) Almost all people in the younger elderly age group had caries experience, with the mean DMFT score being 17.7 teeth. Periodontal disease was observed in 65 % of the younger elderly. 12 % of the younger elderly were edentulous. The reduction in caries experience in the younger elderly is reflected in par-ticular by the increase in the number of teeth retained. Due to the decline in tooth loss since 2005, the proportion of the younger elderly with edentulism has been reduced by half. Although more teeth are being retained and are therefore exposed to the risk of periodontal disease, a decrease in severe periodontal disease was also observed in the younger elderly. Older elderly (aged 75 to 100) Almost all of the older elderly had caries experience. The mean DMFT score in this group was 21.6 teeth. Periodontal disease was observed in 90 % of the older elderly. 33 % of the older elderly were edentulous. Against the backdrop of an ageing society, this oral health study is the first to make representative oral epidemiological data for the older elderly available in Germany. Older elderly with care needs (aged 75 to 100) Almost all older elderlies with care needs had caries experience, with the mean DMFT score being 24.6 teeth. 82 % of the older elderly with care needs had periodontal disease, and 54 % of the older elderly with care needs were edentulous. People with care needs in this age cohort had poorer oral health and showed a lower level of dental care than the older elderly in general. From a behav-ioural health point of view, it was notable that this group required significantly greater assistance with oral hygiene and in organising dental care. Social inequalities From a public health perspective, health inequalities remain a challenging is-sue. Both caries and periodontitis experience show an uneven distribution within the German population. Generally there is an inverse relationship be-tween level of educational attainment and level of oral disease – participants in the study with a higher level of educational attainment tended to have lower levels of oral disease. In this sociomedical context, it is also notable that eden-tulism in the younger elderly varied significantly with level of educational at-tainment. This correlation has, however, decreased slightly since the last sur-vey in 2005. Oral health behaviour Oral health self-care behaviour is a key factor in oral prophylaxis at population level. Tooth cleaning behaviour (frequency, time and duration) has improved significantly over time. Just under half of all children and nearly one in three of the younger elderly report health-sustaining tooth cleaning behaviour. Percep-tions of self-efficacy were likewise distinct – three quarters of study partici-pants stated that the contribution they were able to make to maintain their dental health was “large” or “very large”. Conclusions Overall, there is currently a clear positive trend in oral health in Germany in terms both of caries and periodontitis, which is remarkable in its extent. Interestingly, this positive trend is observed in all age cohorts and across all social strata. All in all, these changes in the prevalence of the two main dental diseases provides clear evi-dence on the concept of compression of morbidity, which essentially states that suc-cessful preventive measures can shift the age of occurrence of (oral) illness upwards and consequently concentrate the burden of illness at a more advanced age. Thus, for example, the prevalence of caries and periodontal disease in the older elderly in DMS V is almost identical to that recorded for the younger elderly less than 10 years ago.
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The world's population is aging, and it has been estimated that by 2050, the number of people 65 years of age and older will reach 1.5 billion. The aging population will be affected by noncommunicable chronic diseases, including diabetes mellitus, cardiovascular disease and cognitive impairment. This important demographic shift includes a reduction in tooth loss/edentulism, particularly in older adults of the developed countries in North America, western Europe and north-east Asia. Therefore, in the future, dental providers will be required to care for an expanded number of older adults who have retained teeth and are medically complex. As the linkage of oral disease and systemic disease has focused on the relationship of periodontitis and noncommunicable chronic diseases, a broad review of ‘geriatric periodontology’ is both timely and important. This volume of Periodontology 2000 covers a range of subjects under this heading. Included are the demographics of an aging world; the effect of aging on stem cell function in the periodontium; the periodontal microbiota associated with aging; the host response in the periodontium of aging individuals; an analysis of the prevalence of periodontitis in the USA on a national, state-wide and community basis; differentiation of physiologic oral aging from disease; treatment of periodontal disease in older adults; implant therapy for older patients; oral disease and the frailty syndrome; the relationship of tooth loss to longevity and life expectancy; and the relationship of periodontal disease to noncommunicable chronic diseases. Although ‘geriatric dentistry’ is not a recognized specialty in dentistry, and ‘geriatric periodontology’ is a descriptive title, the subject of this volume of Periodontology 2000 is critical to the future of clinical dentistry, dental public health and dental research. Any comprehensive focus on older patients can only be accomplished with an emphasis on interprofessional education and practice. If embraced, this shift will allow the dental profession to be more closely aligned with the larger health-care environment, and can improve both oral health and health outcomes for patients seen in the dental office.
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Aim: To compare long-term effects of brushing with an oscillating-rotating power toothbrush or an ADA reference manual toothbrush on pre-existing gingival recession. Materials and methods: In this controlled, prospective, single-blind, parallel group study, healthy subjects with pre-existing recession were randomized and brushed with a power toothbrush (n=55) or an ADA reference manual toothbrush (n=54) for a 3-year study period. Subjects were required to brush their teeth twice daily for 2 minutes using a standard fluoride toothpaste. During the study, subjects were assessed for clinical attachment loss and probing pocket depths to the nearest mm at six sites per tooth by the same calibrated examiner. Gingival recession was calculated at pre-existing sites as the difference between clinical attachment loss and probing pocket depths. Hard and soft oral tissues were examined to assess safety. Results: After 35±2 months, mean gingival recession did not differ significantly between groups, but was significantly reduced from baseline (p<0.001) from 2.35±0.35 mm to 1.90±0.58 mm in the power and from 2.26±0.31 mm to 1.81±0.66 mm in the manual group. Conclusions: Gingival recession in subjects with pre-existing recession was significantly reduced after three years of brushing with either a power or manual toothbrush. This article is protected by copyright. All rights reserved.