Powered vs manual tooth brushing in patients with fixed orthodontic appliances: A systematic review and meta-analysis

Am J Orthod Dentofacial Orthop. 2020 Nov;158(5):639-649. doi: 10.1016/j.ajodo.2020.04.018. Epub 2020 Sep 17.


Objective: The objective of this systematic review and meta-analysis was to compare powered and manual toothbrushes for oral hygiene maintenance in orthodontic patients.

Methods: Electronic databases, including MEDLINE, Scopus, Google scholar, PubMed, Web of Science, the Cochrane Oral Health Group's Trials Register, and CENTRAL, were searched without language restrictions. Randomized clinical trials directly comparing manual and powered toothbrushing including patients with fixed orthodontic appliances reporting predefined outcomes with a follow-up period of at least 4 weeks were included. Using predefined data extraction forms, 2 authors independently undertook data extraction with conflict resolution by the third author. Quality assessment was based on the Cochrane Risk of Bias tool, and overall evidence base was assessed using the Grading of Recommendations Assessment, Development and Evaluation system. A random effects meta-analysis combined the treatment effects across studies.

Results: Five trials were considered appropriate for inclusion in the meta-analysis with 8 trials excluded. There are slight differences in plaque index reduction of 0.05 (-0.04, 0.13) and 0.11 (-0.10, 0.33) at 4 week and 8 week follow up, respectively, favoring manual toothbrushing, but this was not statistically significant. There are slight differences in gingival index reduction of -0.02 (-0.06, 0.02) and -0.01 (-0.05, 0.02) at 4 week and 8 week follow up, respectively, favoring powered brushing, but again, this was not statistically significant. The overall quality of evidence was very low to moderate for the primary outcomes.

Conclusions: Using manual or powered tooth brushing with fixed orthodontic appliances does not reduce plaque or gingival indexes at 4 weeks and 8 weeks. This conclusion is, however, based on low quality of evidence from few studies. Greater standardization of the methodology used is desirable in future trials to increase our confidence in these findings.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Dental Plaque*
  • Humans
  • Oral Health
  • Oral Hygiene
  • Orthodontic Appliances, Fixed*
  • Toothbrushing*