An interactive power toothbrush is great for removing plaque in orthodontic patients.
One of the most significant challenges in orthodontic treatment is to encourage our patients to maintain good oral hygiene. This new study may provide us with an answer!
A large body of research has shown that power toothbrushes are more effective than manual toothbrushes. These have now been combined with wireless apps that provide feedback to users and give real-time feedback on their oral hygiene. These are called interactive toothbrushes. A recent study of an interactive power toothbrush in adolescents showed a 34% reduction in plaque compared to only 1.7% when using a toothbrush. These investigators decided to expand on this work and do a similar study on a group of orthodontic patients.
A team based in Mainz, Germany did this study. Mainz looks very nice. The AJO-DDO published the paper, and it is Open Access, so anyone can read it!
Christina Erbe et al.
https://doi.org/10.1016/j.ajodo.2018.12.013
What did they ask?
They set out to ask;
“What is the plaque removal efficacy and motivational assessment with an interactive power toothbrush vs a manual toothbrush”?
What did they do?
They did a parallel randomised trial with a 1:1 allocation ratio. The PICO was
Participants: Adolescent patients having orthodontic treatment
Intervention: Interactive power toothbrush with Bluetooth technology
Control: Manual toothbrush
Outcome: Plaque measures using a modified Quigley-Hein Index (MQH).
At the start of the study, they identified areas of plaque accumulation. These were called focus areas. They asked all the participants to pay particular attention to these areas. Importantly, if they were using the interactive toothbrush, this was programmed to remind the participant to concentrate on these areas. I thought that this was really clever!
Data was also collected on brushing times and motivation.
They collected data at the start of treatment, then 2 and 6 weeks later.
They did not carry out a sample size calculation and chose a sample size of 60 (30 per group). Randomisation was done by a pre-prepared computer programme and stratified participants on gender and plaque scores. They did not provide any information on the method of allocation concealment. This is important, and I shall discuss this later.
They blinded the examiners to group allocation.
What did they find?
59 participants completed the trial. There were no differences between the groups at the start of treatment in plaque scores. They presented the data for whole mouth plaque scores and also for the focus areas. I do not have enough space to go through both sets of data, but they were similar. I have extracted the whole mouth plaque scores into this table.
| Group | Baseline | Change | % change | Difference ( mean and 95% CI) | ||
| Week 2 | ||||||
| Interactive brush | 3.96 | 1.4 | 36.2% | 0.77 (0.6-0.9) | ||
| Manual | 3.84 | 0.63 | 16.3% | |||
| Week 6 | ||||||
| Interactive brush | 3.92 | 1.8 | 46.3% | 0.8 (0.6-0.9) | ||
| Manual | 3.89 | 0.9 | 24.9% |
These differences were statistically significantly different.
When they looked at the participant feedback, this was very positive for the interactive power toothbrush group. 90% of them responded positively to the statement
“with the app, time goes faster during brushing”.
What did I think?
I thought that this trial provided exciting information on the potential effect of new technology. I was really interested to read about the use of the interactive toothbrush, as I am somewhat obsessed with the technology of this type. I can also understand that, in theory, this should have an effect on the behaviour of our patients, as reminder systems appear to help with other aspects of orthodontic care. For example, toothbrushing and general co-operation.
In general, the trial was nicely done. However, there were a couple of “red flags” that bothered me. These were;
They did not do a power calculation. There are two consequences to this. Firstly, the study may be underpowered and not have sufficient numbers to detect a difference between the groups. Alternatively, there could be too many participants, and this could result in highly significant differences that are not clinically significant. Nevertheless, when we look at the percentage difference between the interventions, this may not be the case.
They did not describe the method of allocation concealment. This means that the trial is at risk of bias because if the operator was aware of likely allocation, they might not enter a participant into the study.
It is also worth mentioning that several of the investigators were employed by Procter and Gamble, who manufactured the interactive toothbrush. They clearly declared this potential conflict.
Finally, the trial only reported on the short term effect of this new intervention. I would really like to see the results of this at the end of orthodontic treatment. Perhaps with another outcome of the incidence of decalcification?
I really hope that the authors continue this study. I am sure that the findings will be interesting.
Emeritus Professor of Orthodontics, University of Manchester, UK.
Dear Obrien,
Two of the main red flags of this trial are Hawthorne effect and Novelty effect. patients are highly subjected to Hawthorne effect when the follow up periods are short as the published study (6 weeks). Novelty effect is explained by a tendency for the subjects to want to do better with a new or improved technology because they are intrigued by it rather than the effect being truly based on the variables under study.
Has there been a research study recently on the efficacy of the new WaterPik devices in plaque removal in patients with orthodontic appliances? I was a dental hygienist before dental school and orthodontics when the WaterPik was not effective in plaque removal. However, recently I purchased a WaterPik with new power settings, and I felt it was more effective than flossing. Do you know of any valid research on this topic?
As a p.s. to Rebecca’s comment: I have had half a dozen patients who have purchased a WaterPik – not on my recommendation, I hasten to add. They all showed an improvement in their oral hygiene and better gingival condition – not perfect, but visibly improved! It might be worth investigating.