The efficacy of powered toothbrushes: A systematic review and network meta‐analysis (2024)

2.1. Focussed PICOS question

The PICOS question³⁵ for this review is: Based on (randomized) controlled clinical trials, what is the efficacy of a PTB with an OR or a HFS technology as compared to an MTB on dental plaque removal following a single‐brushing action in healthy participants?

2.2. Search strategy

A structured and comprehensive search strategy was designed to retrieve all relevant publications that satisfied the study purpose with a direct comparison between:

• ●

  MTB and OR

• ●

  MTB and HFS

• ●

  HFS and OR

Electronic databases were searched for relevant papers. These included The National Library of Medicine, Washington, D.C. (MEDLINE‐PubMed); and the Cochrane Central Register of Controlled Trials (CENTRAL). The last electronic search was performed on 1 August 2021. The search strategy and employed search terms and keywords are presented in Table1. All references cited in the papers selected for this review were checked for additional potentially suitable studies. Hand searching was only performed as part of the Cochrane Worldwide Hand Searching Program uploaded to CENTRAL.

2.3. Screening and selection

Titles and abstracts of the studies obtained from the searches were screened in detail for suitability by two reviewers (TMJAT, DES) using the Rayyan³⁶ web application. The reviewers worked independently and were blinded for each other's results during the screening process. Possible duplicates were identified and checked to eliminate those that were identical. Disagreements in the screening and selection process were resolved by consensus or, if disagreement persisted, by arbitration through a third reviewer (GAW) until consensus was reached. The papers that fulfilled all of the inclusion criteria were processed for data extraction.

Studies were deemed eligible for inclusion if they conformed to the following criteria:

• ●

  Publications written in the English language

• ●

  (Randomized) Controlled Clinical Trials (CCT or RCT)

• ●

  Studies conducted with human participants:

  • ≥18years old.

  • In good general health (without systemic disorder or pregnancy)

  • Without diagnosed periodontitis

  • Without orthodontic fixed appliance and/or removable prosthesis

  • Without dental implants

• ●

  Intervention; powered toothbrush, technologies of interest being oscillating‐rotating and high‐frequency sonic

• ●

  Comparison; manual toothbrush

• ●

  All toothbrushes must be single‐headed

• ●

  Self‐performed brushing by the participant

• ●

  Single‐brushing action

• ●

  Full‐mouth plaque scores assessed according to one of the following most commonly used plaque indices or their modification:

  See Also

  Can I use an Oral-B Electric Toothbrush Daily? | Oral-BDifference between Oral-B Electric Toothbrush Models | FAQThe Advantages of Oral-B Electric Toothbrushes - White Oak Family Dental

  • Quigley and Hein plaque index (Q&HPI³⁷ or the Turesky³⁸modification assessed at two sites per tooth or according to the Lobene³⁹modification up to six sites per tooth).

  • Navy plaque index⁴⁰ or Rustogi modified Navy plaque index (RMNPI)⁴¹

• ●

  Plaque score data available as mean and standard deviation (SD) for pre‐ and post‐brushing and/or incremental plaque score reduction.

2.4. Heterogeneity assessment

Across the studies, the factors used to evaluate the clinical and methodological heterogeneity of the characteristics of the different studies were as follows: study design and evaluation period, subject characteristics, brushing regimen, technology of mode of action, instructions given and plaque indices or their modifications.

As part of the NMA, heterogeneity was statistically tested by the I²statistic, which describes the percentage of variation across studies due to heterogeneity rather than chance. As a rough guide, I² was interpreted as follows: an I² of 0%–40% may indicate unimportant levels of heterogeneity; an I² of 30%–60% may represent moderate heterogeneity; an I² of 50%–90% may represent substantial heterogeneity; and an I²greater than 75% may indicate considerable heterogeneity.⁴²

2.5. Risk of bias and (in)directness

Two reviewers (TMJAT and DES) individually scored the methodological qualities of the included studies according to the method described by Van der Weijden et al.,⁴³ and in greater detail by Keukenmeester et al.⁴⁴ In summary, the study was classified as having an estimated ‘low risk of bias’ when random allocation, defined eligibility criteria, masking of examiners, masking of patients, balanced experimental groups, identical treatment between groups (except for the intervention) and reporting of follow‐up were present. The study was considered to have an estimated ‘moderate risk of bias’ when one of these seven criteria was missing. When two or more of these criteria were missing, the study was estimated to have a ‘high risk of bias’. The potential risk of bias was estimated, and the acquired evidence was graded.

For the assessment of indirectness in the context of the NMA two components were considered: the similarity of the studies in the analysis to the target PICO‐question³⁵ (i.e. the extent to which the evidence relates to the population, intervention(s), comparisons and outcomes of interest); and the transitivity assumption, which is the comparison between two treatments via a third one.⁴⁵

For the present review, risk of bias and the assessment of indirectness were checked for each included study by two reviewers (TMJAT and DES). If disagreements in the quality assessments were found, this was resolved by consensus after discussion.

2.6. Statistical analysis

2.7. Evidence profile

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, as proposed by the GRADE working group,⁵¹ was used to rank the body of evidence emerging from this review. Two reviewers (TMJAT and DES) used the GRADE⁵¹ approach and the Confidence in Network Meta‐Analysis Software (CINeMA)^{52, 53} to evaluate the strength of evidence for results at the end of treatment from the NMA. CINeMA is a web application that simplifies the evaluation of confidence in the findings from an NMA and is based on the framework developed by Salanti et al.²⁵ and refined by Nikolakopoulou et al.⁵³ It is a single page application that communicates to an R back‐end server. In particular, the package's meta and netmeta are used.⁵⁴The CINeMA platform provides a transparent framework to evaluate evidence from systematic reviews with multiple interventions.²⁵ Six domains that affect the level of confidence in the NMA results are considered: (i) within‐study bias, (ii) across‐studies bias, (iii) indirectness, (iv) imprecision, (v) heterogeneity and (vi) incoherence. Any disagreement between the two reviewers was resolved after additional discussion with the third reviewer (GAW).

3.1. Search and selection results

A search of the MEDLINE‐PubMed and Cochrane‐CENTRAL databases identified 4467 unique papers (for details, see Figure1). Screening the titles and abstracts resulted in 100 papers, which were obtained in full text. After careful, extensive and detailed reading, 72 papers were excluded (for details, see online AppendixS1). This resulted in 28^{9, 28, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78} papers for inclusion in this review, describing in total 56 comparisons. Of these, 34 comparisons used the Q&HPI³⁷ or a modification,^{38, 39} and 22 used the RMNPI.^{40, 41} In total, 25 compared the MTB to OR PTBs, nine compared the MTB to HFS PTBs, and 22 compared the HFS to OR PTBs.

3.2. Study characteristics

All but one⁷⁰ of the 28selected studies were RCTs. The characteristics of each study are displayed in online appendix Table S2, and the extracted data are presented by means and SD separately per plaque index of interest (online appendix, Table S3a‐b). The number of participants varied from 12 to 216 per group, and the age ranged from 18 to 69. In 14studies,^{55, 57, 58, 59, 63, 65, 67, 72, 75, 78, 79, 80, 81} a familiarization phase of 2days up to 6weeks prior to the single‐brushing action was part of the research protocol. Instructions were given in a written format in 22studies,^{9, 56, 57, 58, 59, 60, 61, 62, 64, 67, 68, 72, 73, 74, 75, 76, 78, 79, 80, 81, 82} five studies^{55, 63, 65, 77, 81} provided visual instructions to their participants and one study⁷⁰ did not give any instruction (for details, see online appendix Table S2).

3.3. Risk of bias and (in)directness

A summary of the evaluation of the risk of bias in the individual studies is shown in Table S3a‐b in the online appendix, along with the indirectness assessment. Of the 28selected studies, 24 were estimated to have a low risk of bias, three a moderate risk and one a high risk (online appendix, Table S4). The indirectness was scored low for 17 and moderate for 11 comparisons.

3.4. Synthesis of the results

3.5. Heterogeneity assessment

The studies included in the NMA showed considerable heterogeneity,²⁹ as I²statistic values range from 76.3% and 94.7% (Tables2 and ​and4).4). The sub‐analysis per plaque index score shows an unimportant to moderate heterogeneity (0.0%–56.9%) for (M)Q&HPI^{37, 38, 39} and considerable heterogeneity (86.9%–95.9%) for RMNPI^{40, 41}NMA (Tables3 and ​and55).

3.6. Network meta‐analysis graph

The graphs of the NMA⁵³ for post‐brushing scores are shown in Figure2A‐C, and those for the incremental reduction in plaque scores are shown in Figure3A‐C for the overall and subsequent sub‐analyses. It provides a visual synthesis of the evidence comparing the MTB and the two different PTB modes of action (HFS and OR). The different nodes represent a device, risk of bias and sample size. The width of the edge represents the number of included comparisons and the indirectness (for details, see Appendices S14 and S15).

3.7. Confidence in network meta‐analysis

The six domains that affect the level of confidence in the NMA were estimated with CINeMA⁵³ (see Appendices S16–S21). Based on the main concerns regarding heterogeneity and incoherence, a moderate confidence rating of the overall NMA for both post‐brushing and incremental reduction in plaque index scores was present.

3.8. Ranking of interventions

When the toothbrushes are ranked based on the P‐scores as result of the NMA by the program MetaInsight⁴⁷, either based on post‐brushing (Table6) or incremental change (Table7) in plaque scores, the OR ranks first and MTB last. The exception is the sub‐analysis for the post‐brushing scores when (M)Q&HPI^{37, 38, 39} is used, where HFS ranks first. For details on ranking data, see online appendices S8–S13.

3.9. Evidence profile

Table ​Table88 shows the evidence profile based on a summary of the various factors used to rate the quality of evidence and the level of certainty. It accumulates into an estimation of the strength and direction of the recommendation according to GRADE.⁴⁹ With respect to removal of dental plaque, there is a high certainty for a small effect, which supports the recommendation to advise using a PTB rather than an MTB. In addition, there is moderate certainty for a very small beneficial effect for the use of an OR mode of action PTB over a HFS PTB.

4.1. Network meta‐analysis

The aim of this study was to use an NMA to systematically compare and rank the effect of two different PTBs (OR and HFS technology) compared with an MTB with respect to plaque removal as evaluated following a single‐brushing action research model. An NMA is a novel approach that takes the assumptions of a MA one step further.⁸⁴ An NMA²⁹ incorporates direct and indirect comparisons based on the principle of transitivity, which relies on the fact that combined studies have a common comparator.⁸⁵The addition of indirect comparisons by incorporating evidence from other sources makes the results more robust.⁸⁶When the network is well connected and provides both direct and indirect comparisons, these can be pooled together into ‘mixed evidence’, which increases statistical power and the precision of the estimates.⁸⁴The use of added information also allows for more robust recommendations compared with conventional pairwise meta‐analyses.^{87, 88} Consequently, a new evidence hierarchy is proposed with the NMA at the top of the pyramid of evidence, followed by the pairwise MA and SRs without NMA or MA.⁸⁸

From this review, it can be concluded that when combining direct and indirect evidence, there is a significant difference in plaque score reduction after a single‐brushing action in favour of both PTB technologies compared with an MTB. In addition, there is moderate certainty for a very small benefit for the use of an OR PTB mode of action over a HFS PTB. The ranking supports these findings, and this also concurs with the ranking in a recently published NMA by Grender et al. (2020),²⁸ based on studies with a three‐month duration. The results of the present review are congruent with the findings of the recent evaluation of single‐brushing actions¹⁷ and the Cochrane SR,⁸⁹ which were both pairwise comparisons of PTBs and MTBs.

4.2. Plaque indices

From previous reviews on toothbrushing efficacy that have evaluated plaque reduction following a single act of brushing,^{14, 16, 17, 18} it is apparent that the indices most frequently used are Q&HPI^{37, 38, 39} and the RMNPI^{40, 41} and their modifications. Based on this observation, it was decided that these indices would be used as parameters of interest for the present review. This decision mirrors the approach of Elkerbout et al. (2019),¹⁷ who restricted their selection of papers to those that provided outcomes related to these two indices. PTB manufacturers of the different modes of action apparently use various plaque indices to evaluate the efficacy of their products.¹⁷The choice of the plaque score index is presumably related to the manufacturer's preference or a research facility's expertise. Furthermore, in this NMA, most PTB studies evaluating the HFS mode of action assessed plaque according to the criteria of the RMNPI.^{40, 41} Conversely, with an OR mode of action, most evaluations are based on the Q&HPI.^{37, 38, 39} This phenomenon may contribute to reporting bias. In our earlier work,^{14, 16} we have shown that the outcomes with the Q&HPI^{37, 38, 39} result in a smaller plaque score reduction compared with the RMNPI.^{40, 41} This effectively contributes to a wider CI, which is evident from the data presented in Tables2, ​,3,3, ​,4,4, ​,55.

4.3. Oral hygiene instruction

If optimal results are to be achieved with a toothbrush, professional instruction and reinforcement are needed.^{90, 91} Analysis of the included studies revealed that in 22^{9, 56, 57, 58, 59, 60, 61, 62, 64, 67, 68, 72, 73, 74, 75, 76, 78, 79, 80, 81, 82}studies, only written instructions were provided of which three^{74, 76, 78}studies only instructed those using the PTB and gave no instructions for the MTB. In five^{55, 63, 65, 77, 81}studies, visual and /or verbal instructions were given to their participants. In one⁷⁰study, no instructions were provided as the purpose was to evaluate what the effect of brushing was in participants that habitually used either an MTB or PTB (for details, see online appendix Table S2). Considering this outcome, a certain level of bias may be introduced when only those using a PTB received instructions. The efficacy as observed may also have been higher for both the MTB and the PTB if more effort had been put in individual professional instructions.

As the included studies were single‐brushing actions, familiarization with the brushes under research is required, especially if individuals habitually using an MTB are participating in the PTB group. In 14^{55, 57, 58, 59, 63, 65, 67, 72, 75, 78, 79, 80, 81} out of the 28studies, such a familiarization phase was part of the research design. In one study, this phase was not needed as the participants were using the type of brush they used at home. What the impact of the absence of a familiarization phase is on the outcome of the studies was not further analysed but can be considered a limitation. This may have had an impact on the results of brushing with the toothbrush the participants were not familiar with.

4.4. Study design

The study design that evaluates a single‐brushing action provides an assessment under ideal conditions in which all participants comply with the use of the device to which they are randomly assigned.¹⁶ Although the design is clearly restricted to an instant evaluation of one‐time brushing action under controlled circ*mstances, when data indicate that a specific toothbrush shows a greater potential in reducing plaque scores, it can be supposed that it offers improved plaque control over time. Consequently, it may also have long‐term benefits for gingival health.¹⁶The American Dental Association (ADA), in their acceptance programme requirements for an ADA‐seal, requests a minimum study duration of 30‐days to show improved reduction in plaque and gingivitis scores.⁹² Ideally, study should involve a combination of single‐brushing designs and short‐ and long‐term studies that establish robust evidence for a particular toothbrush. The clinical importance of the findings also deserves attention. In this respect, phase IV studies are needed to confirm the long‐term clinical importance of PTB use and for safety surveillance. Studies extending over several years not only provide data related to the prevention of periodontal diseases but also to the prevention of caries.^{93, 94}

The practical difficulty is that PTB manufacturers frequently change toothbrush design or technology, adjust brush heads and introduce other technological improvements. This may result in a long‐term study presenting results on a specific PTB that is no longer available. Recently, an 11‐year prospective population‐based cohort evaluated the longitudinal effects of PTB on periodontal health, caries and tooth loss in an adult population.⁹⁵ It showed an effect in reducing the progression of PD and CAL in the study participants. Therefore, it seems that PTB usage in the long run helps maintain the number of teeth in the oral cavity and reduces the progression of periodontal disease burden.⁹⁵

4.5. Clinical relevance

As with an MA, an SMD as a summary of multiple plaque indices can be calculated with an NMA. Furthermore, a DiffM can be calculated for a specific plaque index. The results of the present NMA show larger differences between the indirect and direct evidence analysis when comparing the outcomes for the SMD with the DiffM. This is presumably due to the variation within and between indices and the subsequent SDs. Hence, it appears legitimate to perform the analysis separately per plaque index score and synthesize the data according to the DiffM. This also allows a direct interpretation of outcomes relative to its original scale, which is crucial for estimating and judging the clinical relevance of the observed difference. This also helps clinicians to interpret the scientific findings in their daily practice. The contribution of indirect data to the overall NMA appears to be more pronounced for the post‐brushing data than the data of the incremental change (see Tables2, ​,3,3, ​,4,4, ​,5).5). This may be because the incremental change between pre‐ and post‐brushing is also affected by the variation in baseline brushing scores. Although there is no statistical difference at baseline, scores can differ due to details in study design choices such as duration of plaque accumulation and dietary instructions. In the present study, this could not be analysed in detail.

For the analysis of post‐brushing scores concerning the MQ&HPI,^{37, 38, 39} only a significant difference is found for the direct comparisons between the OR PTB and MTB. When the incremental change in plaque scores is considered, analysis with the RMNPI^{40, 41}shows a significant difference irrespective of the inclusion of indirect comparisons (Table5). The incremental change can also be used for interpreting the clinical relevance. The DiffM of MQ&HPI^{37, 38, 39}scores range from 0.04 to 0.18 on a scale of 0–5 (Table5), and for RMNP^{40, 41} index, scores range from 0.05 to 0.13 on a scale of 0–1. The latter translates approximately as a 13% difference, a figure that could result in a clinically significant effect on gingival health.⁹⁶

4.6. Should everyone use a PTB?

Toothbrushes in general are the most recommended oral care product.⁹⁷The conclusion that a PTB removes more dental plaque than an MTB raises the question whether people should always use a PTB. As this significantly impacts professional recommendations and public knowledge, such a message should be posted with vigilance. Evidence‐based advice should include details of PTB costs and should not be limited to plaque removal effectiveness but should include the maintenance or improvement of periodontal health.

In 2006, Porter introduced the term value‐based health care (VBH).⁹⁸This concept is based on a cost‐effectiveness principle and is currently well integrated into the medical field, particularly in Western societies.⁹⁸Value‐based oral health care (VBOHC) is about improving people's oral health outcomes divided by the costs—that is, ‘patient health outcomes achieved per dollar spent’.^{99, 100} Currently, such an analysis for something as basic as a toothbrush has not been performed, and certainly not for PTBs and their different modes of action. For such an analysis, there are several aspects to consider. First, the cost of a PTB is substantially more than an MTB and also comes with a variety of models and prices. Second, it needs to be ascertained how much the expected improvement in plaque removal and subsequent preventive effect of improved gingival health and reduced caries risk will cost. As periodontitis accounts for a considerable proportion of edentulism and masticatory dysfunction, it has a negative impact on general health and results in significant dental care costs.^{101, 102}Thus, indirectly, adequate plaque removal reduces the need for treatment and, consequently, toothbrushing presumably reduces oral healthcare costs in both the short and long term. Based on this complex series of considerations and consequent calculations, VBOHC can be used to gain more insights into which oral health outcome can be obtained for a specific person by using a PTB. This insight will answer the question raised earlier of whether the financial expense for a PTB is realistic and beneficial for everyone.

4.7. Limitations and recommendations

• ‐

  Only publications written in the English language were included in this SR and NMA. This prerequisite may have introduced a language bias, although the extent and effect of this may be negligible due to the shift towards publications in English in recent decades and the high number of included studies.²⁹

• ‐

  Only full‐text publications were considered, and no abstracts from scientific meetings or manufacturers’ data on file were sought. This restriction may have introduced a publication bias. However, internationally published papers have been through the peer review process, which is intended to safeguard content quality.¹⁰³

• ‐

  Blinding participants during clinical trials comparing MTB and PTB is not possible. Participants will see and experience the difference, and this is also true for the different PTB modes of action (ie OR and HFS.)

• ‐

  This SR included publications dated from 1992, and the most recent study was from 2020. The changes in toothbrusg design occurring in the intervening 28years could possibly affect the outcome. Both MTBs and PTBs have undergone technological improvements over recent decades.¹⁰⁴While the original technology of the OR movements or sonic vibrations is essentially unchanged, it has been optimized, and this also applies to brush head design.

• ‐

  The new development of digital software to optimize patients’ oral hygiene performance—such as timers, pressure sensors, apps, and artificial‐intelligence brushing recognition and guidance—is not considered in this review.

6.1. Scientific rationale for the study

Toothbrushing is considered the most efficient way to remove dental plaque and prevent periodontal diseases. At present, no network meta‐analysis (NMA) of the available literature has been performed concerning the efficacy of different powered toothbrush technologies on plaque removal.

6.2. Principal findings

The NMA demonstrated that an oscillating‐rotating (OR) or a high‐frequency sonic (HFS) powered toothbrush (PTB) is more effective than a manual toothbrush. When comparing the two PTB technologies, OR ranks higher than HFS.

6.3. Practical implications

When recommending a toothbrush to a patient, a PTB is more effective than a manual toothbrush and should be considered the first choice. The clinical relevance of the very small but significant difference in favour of OR over HFS technology needs further appraisal based on long‐term studies.

Supplementary Material

1. Chapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Clin Periodontol. 2018;45:S68‐S77. Blackwell Munksgaard; doi: 10.1111/jcpe.12940 [PubMed] [CrossRef] [Google Scholar]

2. Murakami S, Mealey BL, Mariotti A, Chapple ILC. Dental plaque–induced gingival conditions. J Clin Periodontol. 2018;45:S17‐S27. doi: 10.1111/jcpe.12937 [PubMed] [CrossRef] [Google Scholar]

3. Ramseier CA, Anerud A, Dulac M, et al. Natural history of periodontitis: disease progression and tooth loss over 40 years. J Clin Periodontol. 2017;44:1182‐1191. doi: 10.1111/jcpe.12782 [PubMed] [CrossRef] [Google Scholar]

4. Schätzle M, Löe H, Bürgin W, Ånerud Å, Boysen H, Lang NP. Clinical course of chronic periodontitis: I. Role of Gingivitis. J Clin Periodontol. 2003;30:887‐901. doi: 10.1034/j.1600-051X.2003.00414.x [PubMed] [CrossRef] [Google Scholar]

5. Loe H. Oral hygiene in the prevention of caries and periodontal disease. Int Dent J. 2000;50:129‐139. [PubMed] [Google Scholar]

6. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. J Clin Periodontol. 1978;5:133‐151. doi: 10.1111/j.1600-051X.1978.tb01914.x [PubMed] [CrossRef] [Google Scholar]

7. Axelsson P, Lindhe J. The significance of maintenance care in the treatment of periodontal disease. J Clin Periodontol. 1981;8:281‐294. doi: 10.1111/j.1600-051X.1981.tb02039.x [PubMed] [CrossRef] [Google Scholar]

8. Axelsson P, Nyström B, Lindhe J. The long‐term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults: results after 30 years of maintenance. J Clin Periodontol. 2004;31:749‐757. doi: 10.1111/j.1600-051X.2004.00563.x [PubMed] [CrossRef] [Google Scholar]

9. Goyal CR, Qaqish J, He T, Walters P, Grender J, Biesbrock AR. A randomized 12‐week study to compare the gingivitis and plaque reduction benefits of a rotation‐oscillation power toothbrush and a sonic power toothbrush. J Clin Dent. 2009;20:93‐98. [PubMed] [Google Scholar]

10. McCracken GI, Heasman L, Stacey F, Kelly PJ, Heasman PA. Testing the efficacy of plaque removal of a prototype brush head for a powered toothbrush. J Clin Periodontol. 2000;27:542‐548. doi: 10.1034/j.1600-051x.2000.027008542.x [PubMed] [CrossRef] [Google Scholar]

12. Janusz K, Nelson B, Bartizek RD, Walters PA, Biesbrock A. Impact of a novel power toothbrush with smartguide technology on brushing pressure and thoroughness. J Contemp Dent Pract. 2008;9:001‐008. doi: 10.5005/jcdp-9-7-1 [PubMed] [CrossRef] [Google Scholar]

13. Toniazzo MP, Nodari D, Muniz FWMG, Weidlich P. Effect of mHealth in improving oral hygiene: a systematic review with meta‐analysis. J Clin Periodontol. 2019;46:297‐309. doi: 10.1111/jcpe.13083 [PubMed] [CrossRef] [Google Scholar]

14. Rosema N, Slot D, van Palenstein HW, Wiggelinkhuizen L, Van der Weijden G. The efficacy of powered toothbrushes following a brushing exercise: a systematic review. Int J Dent Hyg. 2016;14:29‐41. doi: 10.1111/idh.12115 [PubMed] [CrossRef] [Google Scholar]

15. Wang P, Xu Y, Zhang J, et al. Comparison of the effectiveness between power toothbrushes and manual toothbrushes for oral health: a systematic review and meta‐analysis. Acta Odontol Scand. 2020;78:265‐274. doi: 10.1080/00016357.2019.1697826 [PubMed] [CrossRef] [Google Scholar]

16. Slot D, Wiggelinkhuizen L, Rosema N, Van der Weijden G. The efficacy of manual toothbrushes following a brushing exercise: a systematic review. Int J Dent Hyg. 2012;10:187‐197. doi: 10.1111/j.1601-5037.2012.00557.x [PubMed] [CrossRef] [Google Scholar]

17. Elkerbout TA, Slot DE, Rosema NAM, Van der Weijden GA. How effective is a powered toothbrush as compared to a manual toothbrush? A systematic review and meta‐analysis of single brushing exercises. Int J Dent Hyg. 2020;18:1‐10. doi: 10.1111/idh.12401 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

18. van der Sluijs E, Slot DE, Hennequin‐Hoenderdos NL, Valkenburg C, van der Weijden GA. Dental plaque score reduction with the oscillating‐rotating power toothbrush and the high frequency sonic power toothbrushes: a systematic review and meta‐analysis of single brushing exercises. Int J Dent Hyg. 2021;19:78‐92. doi: 10.1111/idh.12463 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

19. Claydon N. Comparative single‐use plaque removal by toothbrushes of different designs. J Clin Periodontol. 1996;23:1112‐1116. doi: 10.1111/j.1600-051X.1996.tb01812.x [PubMed] [CrossRef] [Google Scholar]

20. Egelberg J, Claffey N. Role of mechanical dental plaque removal in prevention and therapy of caries and periodontal diseases. Consensus Report of Group B. In: Lang NP, Attström R, Löe H, eds. Proceedings of the European Workshop on Mechanical Plaque Control. Quintessence; 1998:169‐172. [Google Scholar]

21. Deacon SA, Glenny A‐M, Deery C, et al. Different powered toothbrushes for plaque control and gingival health. Cochrane Database Syst Rev. 2020;2020: Published online December 8, 2010. doi: 10.1002/14651858.cd004971.pub2 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

22. El‐chami H, Younis A, Brignardello‐Petersen R. Efficacy of oscillating rotating versus side‐to‐side powered toothbrushes on plaque and gingival index reduction: a systematic review. J Am Dent Assoc. 2021;152:115‐126.e4. doi: 10.1016/j.adaj.2020.10.002 [PubMed] [CrossRef] [Google Scholar]

23. Clark‐Perry D, Levin L. Systematic review and meta‐analysis of randomized controlled studies comparing oscillating‐rotating and other powered toothbrushes. J Am Dent Assoc. 2020;151:265‐275.e6. doi: 10.1016/j.adaj.2019.12.012 [PubMed] [CrossRef] [Google Scholar]

24. Van Der Weijden FA, Slot DE. Efficacy of homecare regimens for mechanical plaque removal in managing gingivitis a meta review. J Clin Periodontol. 2015;42:S77‐S91. doi: 10.1111/jcpe.12359 [PubMed] [CrossRef] [Google Scholar]

25. Salanti G, Del GC, Chaimani A, Caldwell DM, Higgins JPT. Evaluating the quality of evidence from a network meta‐analysis. PLoS One. 2014;9: doi: 10.1371/journal.pone.0099682 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

26. Rouse B, Chaimani A, Li T. Network meta‐analysis: an introduction for clinicians. Intern Emerg Med. 2017. doi: 10.1007/s11739-016-1583-7 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

27. Chaimani A, Salanti G. Using network meta‐analysis to evaluate the existence of small‐study effects in a network of interventions. Res Synth Methods. 2012. doi: 10.1002/jrsm.57 [PubMed] [CrossRef] [Google Scholar]

28. Grender J, Adam R, Zou Y. The effects of oscillating‐rotating electric toothbrushes on plaque and gingival health: a meta‐analysis. Am J Dent. 2020;33:3‐11. doi: 10.31525/ct1-nct04017507 [PubMed] [CrossRef] [Google Scholar]

29. Higgins J, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.0 (updated July 2019). Cochrane, 2019. Available from www.training.cochrane.org/handbook, Accessed June 3, 2020. [PMC free article] [PubMed]

30. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta‐analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097. 10.1371/journal.pmed.1000097 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

31. Beller EM, Glasziou PP, Altman DG, et al. PRISMA for abstracts: reporting systematic reviews in journal and conference abstracts. PLoS Med. 2013;10: doi: 10.1371/journal.pmed.1001419 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

32. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. PLoS Med. 2020;2021:18. doi: 10.1371/journal.pmed.1003583 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

33. Hutton B, Salanti G, Caldwell DM, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta‐analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162:777‐784. doi: 10.7326/M14-2385 [PubMed] [CrossRef] [Google Scholar]

35. Stillwell SB, Fineout‐Overholt E, Melnyk BM, Williamson KM. Evidence‐based practice, step by step: asking the clinical question. AJN, Am J Nurs. 2010;110:58‐61. doi: 10.1097/01.NAJ.0000368959.11129.79 [PubMed] [CrossRef] [Google Scholar]

36. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan‐a web and mobile app for systematic reviews. Syst Rev. 2016;5(1): doi: 10.1186/s13643-016-0384-4 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

37. Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc. 1962;65:26‐29. doi: 10.14219/jada.archive.1962.0184 [PubMed] [CrossRef] [Google Scholar]

38. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of victamine C. J Periodontol. 1970;41:41‐43. doi: 10.1902/jop.1970.41.41.41 [PubMed] [CrossRef] [Google Scholar]

39. Lobene RR, Soparkar PM, Newman MB. Use of dental floss. Effect on plaque and gingivitis. Clin Prev Dent. 1982;4:5‐8. [PubMed] [Google Scholar]

40. Elliott JR, Bowers GM, Clemmer BA, Rovelstad GH. Evaluation of an oral physiotherapy center in the reduction of bacterial plaque and periodontal disease. J Periodontol. 1972;43:221‐224. doi: 10.1902/jop.1972.43.4.221 [PubMed] [CrossRef] [Google Scholar]

41. Rustogi KN, Curtis JP, Volpe AR, Kemp JH, McCool JJ, Korn LR. Refinement of the Modified Navy Plaque Index to increase plaque scoring efficiency in gumline and interproximal tooth areas. J Clin Dent. 1992;3(Suppl C):C9‐C12. [PubMed] [Google Scholar]

42. Ryan R. Cochrane Consumers and Communication Review Group. ‘Heterogeneity and subgroup analyses in Cochrane Consumers and Communication Group reviews: planning the analysis at protocol stage. December 2016. http://cccrg.cochrane.org, Accessed June 1, 2021.

43. Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar bone dimensional changes of post‐extraction sockets in humans: a systematic review. J Clin Periodontol. 2009;36:1048‐1058. doi: 10.1111/j.1600-051X.2009.01482.x [PubMed] [CrossRef] [Google Scholar]

44. Keukenmeester R, Slot DE, Putt MS, Van der Weijden GA. The effect of sugar‐free chewing gum on plaque and clinical parameters of gingival inflammation: a systematic review. Int J Dent Hyg. 2013;11:2‐14. doi: 10.1111/j.1601-5037.2012.00562.x [PubMed] [CrossRef] [Google Scholar]

45. Chaimani A, Caldwell DM, Li T, Higgins JP, Salanti G. Undertaking network meta‐analyses. Cochrane Handb Syst Rev Interv. 2019:285‐320. doi: 10.1002/9781119536604.ch11 [CrossRef] [Google Scholar]

46. Van Strydonck DAC, Slot DE, Van der Velden U, Van der Weijden F. Effect of a chlorhexidine mouthrinse on plaque, gingival inflammation and staining in gingivitis patients: a systematic review. J Clin Periodontol. 2012;39:1042‐1055. doi: 10.1111/j.1600-051X.2012.01883.x [PubMed] [CrossRef] [Google Scholar]

47. Owen RK, Bradbury N, Xin Y, Cooper N, Sutton A. MetaInsight: an interactive web‐based tool for analyzing, interrogating, and visualizing network meta‐analyses using R‐shiny and netmeta. Res Synth Methods. 2019;10:569‐581. doi: 10.1002/jrsm.1373 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

49. Rücker G, Schwarzer G. Ranking treatments in frequentist network meta‐analysis works without resampling methods. BMC Med Res Methodol. 2015;15:58. doi: 10.1186/s12874-015-0060-8 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

50. Salanti G, Ades AE, Ioannidis JPA. Graphical methods and numerical summaries for presenting results from multiple‐treatment meta‐analysis: an overview and tutorial. J Clin Epidemiol. 2011;64:163‐171. doi: 10.1016/j.jclinepi.2010.03.016 [PubMed] [CrossRef] [Google Scholar]

51. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Chinese J Evidence‐Based Med. 2009;9:8‐11. doi: 10.1136/bmj.39489.470347.AD [PMC free article] [PubMed] [CrossRef] [Google Scholar]

52. Papakonstantinou T, Nikolakopoulou A, Higgins JPT, Egger M, Salanti G. CINeMA: software for semiautomated assessment of the confidence in the results of network meta‐analysis. Campbell Syst Rev. 2020;16: doi: 10.1002/cl2.1080 [CrossRef] [Google Scholar]

53. Nikolakopoulou A, Higgins JPT, Papakonstantinou T, et al. CINeMA: an approach for assessing confidence in the results of a network meta‐analysis. PLoS Med. 2020;17:e1003082. doi: 10.1371/journal.pmed.1003082 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

54. Rücker G, Schwarzer G, Krahn U, König J. netmeta: network meta‐analysis with R. R package version 0.5‐0. 2014. Availiable: http://CRAN.R‐project.org/package=netmeta Accessed June 1, 2021

55. Robinson PJ, Maddalozzo D, Breslin S. A six‐month clinical comparison of the efficacy of the Sonicare^® and the Braun Oral‐B^® electric toothbrushes on improving periodontal health in adult periodontitis patients. J Clin Dent. 1997;8:4‐9. [PubMed] [Google Scholar]

56. Williams K, Rapley K, Haun J, et al. Comparison of rotation/oscillation and sonic power toothbrushes on plaque and gingivitis for 10 weeks. Am J Dent. 2009;22:345‐349. http://www.ncbi.nlm.nih.gov/pubmed/20178210. Accessed June 1, 2021. [PubMed] [Google Scholar]

57. Ayad F, Petrone DM, Wachs GN, Mateo LR, Chaknis P, Panagakos F. Comparative efficacy of a specially engineered sonic powered toothbrush with unique sensing and control technologies to two commercially available power toothbrushes on established plaque and gingivitis. J Clin Dent. 2012;23:A5‐A10. [PubMed] [Google Scholar]

58. Biesbrock AR, Bartizek RD, Walters PA, et al. Clinical evaluations of plaque removal efficacy: an advanced rotating‐oscillating power toothbrush versus a sonic toothbrush. J Clin Dent. 2007;18:106‐111. [PubMed] [Google Scholar]

59. Biesbrock AR, Walters PA, Bartizek RD, Goyal CR, Qaqish JG. Plaque removal efficacy of an advanced rotation‐oscillation power toothbrush versus a new sonic toothbrush. Am J Dent. 2008;21:185‐188. [PubMed] [Google Scholar]

60. Gallob JT, Lynch M, Charles C, et al. A randomized trial of ethyl lauroyl arginate‐containing mouthrinse in the control of gingivitis. J Clin Periodontol. 2015;42:740‐747. doi: 10.1111/jcpe.12428 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

61. Nathoo S, Mankodi S, Mateo LR, Chaknis P, Panagakos F. A clinical study comparing the supragingival plaque and gingivitis efficacy of a specially engineered sonic powered toothbrush with unique sensing and control technologies to a commercially available manual flat‐trim toothbrush. J Clin Dent. 2012;23(SPEC. ISS. A):A11–6. [PubMed] [Google Scholar]

62. Nathoo S, Mateo LR, Chaknis P, et al. Efficacy of two different toothbrush heads on a sonic power toothbrush compared to a manual toothbrush on established gingivitis and plaque. J Clin Dent. 2014;25:65‐70. [PubMed] [Google Scholar]

63. Sharma NC, Galustians J, Qaqish J, Cugini M. A comparison of two electric toothbrushes with respect to plaque removal and subject preference. Am J Dent. 1998;11:S29‐33. [PubMed] [Google Scholar]

64. Sharma NC, Goyal CR, Qaqish JG, Cugini MA, Thompson MC, Warren PR. Single‐use plaque removal efficacy of three power toothbrushes. J Dent. 2005;33S1:11‐15. [PubMed] [Google Scholar]

65. Heasman PA, Stacey F, Heasman L, Sellers P, Macgregor IDM, Kelly PJ. A comparative study of the Philips HP 735, Braun/Oral B D7 and the Oral B 35 Advantage toothbrushes. J Clin Periodontol. 1999;26:85‐90. doi: 10.1034/j.1600-051X.1999.260204.x [PubMed] [CrossRef] [Google Scholar]

66. Sharma NC, Lyle DM, Qaqish JG, Galustians J. Evaluation of the plaque removal efficacy of three power toothbrushes. J Int Acad Periodontol. 2006;8:83‐88. [PubMed] [Google Scholar]

67. Sharma NC, Qaqish J, Klukowska M, Grender J, Rooney J. The plaque removal efficacy of a novel power brush head. J Clin Dent. 2011;22:19‐22. [PubMed] [Google Scholar]

68. Strate J, Cugini MA, Warren PR, Qaqish JG, Galustians HJ, Sharma NC. A comparison of the plaque removal efficacy of two power toothbrushes: Oral‐B Professional Care Series versus Sonicare Elite. Int Dent J. 2005;55:151‐156. doi: 10.1111/j.1875-595X.2005.tb00312.x [PubMed] [CrossRef] [Google Scholar]

69. Terézhalmy GT, Bartizek RD, Biesbrock AR. Relative plaque removal of three toothbrushes in a nine‐period crossover study. J Periodontol. 2005;76:2230‐2235. doi: 10.1902/jop.2005.76.12.2230 [PubMed] [CrossRef] [Google Scholar]

70. Rosema NAM, Adam R, Grender JM, Van der Sluijs E, Supranoto SC, Van der Weijden GA. Gingival abrasion and recession in manual and oscillating‐rotating power brush users. Int J Dent Hyg. 2014;12:257‐266. doi: 10.1111/idh.12085 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

71. Van der Weijden GA, Timmerman MF, Reijerse E, Snoek CM, Velden U. Comparison of an oscillating/rotating electric toothbrush and a “sonic” toothbrush in plaque‐removing ability. A professional toothbrushing and supervised brushing study. J Clin Periodontol. 1996;23:407‐411. doi: 10.1111/j.1600-051x.1996.tb00565.x [PubMed] [CrossRef] [Google Scholar]

72. Klukowska M, Grender JM, Timm H. A single‐brushing study to compare plaque removal efficacy of a new power brush to an ADA reference manual toothbrush. Am J Dent. 2012;25(SPEC. ISSUE A):10A‐13A. [PubMed] [Google Scholar]

73. Kulkarni P, Singh DK, Jalaluddin M. Comparison of efficacy of manual and powered toothbrushes in plaque control and gingival inflammation: a clinical study among the population of east indian region. J Int Soc Prev Community Dent. 2017;7:168‐174. doi: 10.4103/jispcd.JISPCD_133_17 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

74. Kurtz B, Reise M, Klukowska M, Grender JM, Timm H, Sigusch BW. A randomized clinical trial comparing plaque removal efficacy of an oscillating–rotating power toothbrush to a manual toothbrush by multiple examiners. Int J Dent Hyg. 2016;14:278‐283. doi: 10.1111/idh.12225 [PubMed] [CrossRef] [Google Scholar]

75. Moritis K, Delaurenti M, Johnson MR, Berg J, Boghosian AA. Comparison of the Sonicare Elite and a manual toothbrush in the evaluation of plaque reduction. Am J Dent. 2002;15 Spec No:23B‐25B. http://www.ncbi.nlm.nih.gov/pubmed/12516678, Accessed June 1, 2021. [PubMed] [Google Scholar]

76. Pizzo G, Licata ME, Pizzo I, D’Angelo M. Plaque removal efficacy of power and manual toothbrushes: a comparative study. Clin Oral Investig. 2010;14:375‐381. doi: 10.1007/s00784-009-0303-3 [PubMed] [CrossRef] [Google Scholar]

77. Re D, Augusti G, Battaglia D, Giannì AB, Augusti D. Is a new sonic toothbrush more effective in plaque removal than a manual toothbrush?Eur J Paediatr Dent. 2015;16:13‐18. [PubMed] [Google Scholar]

78. Renton‐Harper P, Addy M, Newcombe RG. Plaque removal with the uninstructed use of electric toothbrushes: comparison with a manual brush and toothpaste slurry. J Clin Periodontol. 2001;28:325‐330. doi: 10.1034/j.1600-051x.2001.028004325.x [PubMed] [CrossRef] [Google Scholar]

79. Putt M, Milleman J, Jenkins W, Schmitt P, Master A, Strate J. A randomized, crossover‐design study to investigate the plaque removal efficacy of two power toothbrushes: Philips Sonicare FlexCare and Oral‐B Triumph. Compend Contin Educ Dent. 2008;29(56):58‐64. [PubMed] [Google Scholar]

80. Williams K, Rapley K, Huan J, et al. A study comparing the plaque removal efficacy of an advanced rotation‐oscillation power toothbrush to a new sonic toothbrush. J Clin Dent. 2008;19:154‐158. http://www.ncbi.nlm.nih.gov/pubmed/19278087, Accessed June 1, 2021. [PubMed] [Google Scholar]

81. Adam R, Erb J, Grender J. Randomized controlled trial assessing plaque removal of an oscillating‐rotating electric toothbrush with micro‐vibrations. Int Dent J. 2020;70(S1):S22‐S27. doi: 10.1111/idj.12568 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

82. Yankell SL, Emling RC. A thirty‐day safety and efficacy evaluation of the Rowenta, Braun and Sonicare powered toothbrushes and a manual toothbrush. J Clin Dent. 1997;8:120‐123. http://www.ncbi.nlm.nih.gov/pubmed/26630722, Accessed June 1, 2021. [PubMed] [Google Scholar]

83. Smiley CJ, Tracy SL, Abt E, et al. Evidence‐based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. J Am Dent Assoc. 2015;146:525‐535. doi: 10.1016/j.adaj.2015.01.026 [PubMed] [CrossRef] [Google Scholar]

84. Cipriani A, Higgins JPT, Geddes JR, Salanti G. Conceptual and technical challenges in network meta‐analysis. Ann Intern Med. 2013;159:130‐137. doi: 10.7326/0003-4819-159-2-201307160-00008 [PubMed] [CrossRef] [Google Scholar]

85. Catalá‐López F. Evaluation of comparative treatment effects using indirect comparisons. Rev Española Cardiol (English Ed). 2013;66:156‐157. doi: 10.1016/j.rec.2012.09.013 [PubMed] [CrossRef] [Google Scholar]

86. Salanti G. Indirect and mixed‐treatment comparison, network, or multiple‐treatments meta‐analysis: many names, many benefits, many concerns for the next generation evidence synthesis tool. Res Synth Methods. 2012;3:80‐97. doi: 10.1002/jrsm.1037 [PubMed] [CrossRef] [Google Scholar]

87. Rouse B, Cipriani A, Shi Q, Coleman AL, Dickersin K, Li T. Network meta‐analysis for clinical practice guidelines: a case study on first‐line medical therapies for primary open‐angle glaucoma. Ann Intern Med. 2016;164:674‐682. doi: 10.7326/M15-2367 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

88. Leucht S, Chaimani A, Cipriani AS, Davis JM, Furukawa TA, Salanti G. Network meta‐analyses should be the highest level of evidence in treatment guidelines. Eur Arch Psychiatry Clin Neurosci. 2016;266:477‐480. doi: 10.1007/s00406-016-0715-4 [PubMed] [CrossRef] [Google Scholar]

89. Yaacob M, Worthington HV, Deacon SA, et al. Powered versus manual toothbrushing for oral health. Cochrane Database Syst Rev. 2014;2014: doi: 10.1002/14651858.CD002281.pub3 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

90. Van der Weijden GA, Timmerman MF, Reijerse E, et al. The long‐term effect of an oscillating/rotating electric toothbrush on gingivitis. An 8‐month clinical study. J Clin Periodontol. 1994;21:139‐145. doi: 10.1111/j.1600-051x.1994.tb00292.x [PubMed] [CrossRef] [Google Scholar]

91. van der Weijden GA, Danser MM, Nijboer A, Timmerman MF, van der Velden U. The plaque‐removing efficacy of an oscillating/rotating toothbrush: a short‐term study. J Clin Periodontol. 1993;20:273‐278. doi: 10.1111/j.1600-051X.1993.tb00357.x [PubMed] [CrossRef] [Google Scholar]

93. Chapple ILC, Bouchard P, Cagetti MG, et al. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol. 2017;44:S39‐S51. doi: 10.1111/jcpe.12685 [PubMed] [CrossRef] [Google Scholar]

94. Jepsen S, Blanco J, Buchalla W, et al. Prevention and control of dental caries and periodontal diseases at individual and population level: consensus report of group 3 of joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol. 2017;44:S85‐S93. doi: 10.1111/jcpe.12687 [PubMed] [CrossRef] [Google Scholar]

95. 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;46:713‐722. doi: 10.1111/jcpe.13126 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

96. Van der Weijden GA, Timmerman MR, Reijerse E, et al. The long‐term effect of an oscillating/rotating electric toothbrush on gingivitis: an 8‐month clinical study. J Clin Periodontol. 1994;21:139‐145. doi: 10.1111/j.1600-051X.1994.tb00292.x [PubMed] [CrossRef] [Google Scholar]

97. Wainwright J, Sheiham A. An analysis of methods of toothbrushing recommended by dental associations, toothpaste and toothbrush companies and in dental texts. Br Dent J. 2014;217:E5. doi: 10.1038/sj.bdj.2014.651 [PubMed] [CrossRef] [Google Scholar]

98. Porter ME. What is value in health care?N Engl J Med. 2010;363:2477‐2481. doi: 10.1056/NEJMp1011024 [PubMed] [CrossRef] [Google Scholar]

99. Listl S, Birch S. Reconsidering value for money in periodontal treatment. J Clin Periodontol. 2013;40:345‐348. doi: 10.1111/jcpe.12085 [PubMed] [CrossRef] [Google Scholar]

100. Listl S. Value‐based oral health care: moving forward with dental patient‐reported outcomes. J Evid Based Dent Pract. 2019;19:255‐259. doi: 10.1016/j.jebdp.2019.101344 [PubMed] [CrossRef] [Google Scholar]

101. Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Periodontol. 2018;89:S173‐S182. doi: 10.1002/JPER.17-0721 [PubMed] [CrossRef] [Google Scholar]

102. Tonetti MS, Jepsen S, Jin L, Otomo‐Corgel J. Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of mankind: a call for global action. J Clin Periodontol. 2017;44:456‐462. doi: 10.1111/jcpe.12732 [PubMed] [CrossRef] [Google Scholar]

104. Penick C. Power toothbrushes: a critical review. Int J Dent Hyg. 2004;2:40‐44. doi: 10.1111/j.1601-5037.2004.00048.x [PubMed] [CrossRef] [Google Scholar]