Have you ever felt overwhelmed by the sheer number of publications that discuss the merits of manual and powered toothbrushes? How do you know which one is the most accurate? Understanding the requirements for the American Dental Association (ADA) Seal of Acceptance and how companies fund their research may alleviate some confusion.
First and foremost, dental hygienists must know what to look for in dental product research articles to assist them in making product recommendations to patients/consumers.
The best place to begin when reviewing clinical and laboratory studies on products is peer-reviewed journals.1 They have editorial review boards whose members have expertise in varying areas and can identify problems with research methodology, statistical analysis, and the application of the conclusions. Respectable peer-reviewed journals take the responsibility of publishing truthful information very seriously. Peer-reviewed journals must be careful to prevent reviewer biases and conflicts of interest and to ensure that news releases contain accurate information. News releases often do not mention study limitations or industry funding or may exaggerate the importance of findings.
A Balancing Act
Recently several metropolitan newspapers reported on powered toothbrushes.2 The articles focused on a meeting in Boston and quoted the Cochrane Collaboration, an influential nonprofit group from England that evaluates medical and dental care. The Cochrane presentation concluded that a specific powered toothbrush outperformed other powered and manual brushes.3 Since only this one source was quoted, the newspaper stories were incomplete, and therefore, not reliable. No references were provided, yet many consumers accept media reports with a high level of confidence.
Isabel Garcia from the National Institute of Dental and Craniofacial Research noted that these reviews are helpful in sorting through the literature, however, they are not necessarily comprehensive.2 Ensuring that dental care is based on evidence is important but the information must be balanced.
Biased results are the exception and not the rule in industry-sponsored research. Industry is required to perform clinical and laboratory testing to get new products on the market and, in the case of dentistry, in order to obtain the ADA Seal of Approval.
The ideal setting for industry sponsors to get objective, unbiased data regarding their product testing is within a university setting. This does not mean that private entities that test products in vivo and in vitro always provide biased results, but ideally, the university setting ensures the most unbiased results due to the series of checks and balances that exists between institutional review boards and reviews of the protocol methodologies.
Why do the sponsors pay the universities to conduct the research? Simply because most universities cannot or are not allowed to perform private testing for companies and certainly do not have the budgets to perform such testing without financial support. If the companies follow the guidelines required to a get a product to market with the ADA Seal of Acceptance, the testing is very expensive.
Advertisements that claim the product has the ADA Seal of Acceptance are required to have the testing information and results available upon request.4 However, you may find an advertisement that says, “Study data on file.” If you contact the company for this information and it is not readily available, you should question the legitimacy of the claims.
Seal of Approval
The ADA has been trying to ensure the safety and efficacy of dental products for more than 125 years. Because a company does a study following the testing guidelines for the ADA Seal of Acceptance, it does not guarantee the product will receive acceptance. Additionally, the ADA Seal of Acceptance program is not required to sell a product but, to date, approximately 350 companies have participated in the program.4 There are approximately 1,300 products that carry the ADA Seal of Acceptance and of those, about 30% are consumer products.4
When products are submitted for the ADA Seal of Acceptance, they are then evaluated by more than 100 ADA consultants, including members of the ADA’s Council on Scientific Affairs, ADA selected evaluators, and staff scientists.4 Once accepted for the ADA Seal of Acceptance, the ADA must review all advertising claims for the products that will bear the seal and will only allow claims that are supported by appropriate clinical and laboratory data. The Seal of Acceptance is an assurance that the product has met rigorous testing standards that are independent, and is designed to assist consumers and dental health care professionals make informed decisions and protect against untrue or unsupported claims.
Certainly there are many powered and manual toothbrushes on the market, which have been measured against each other. Comparison of the efficacy and features of powered and manual toothbrushes reveals that even though various brands have different mechanisms of action, powered toothbrushes reliably remove more biofilm than manual toothbrushes. This has has been proven clinically in numerous trials.4 In the future, there may be a “magic” powered brush that can be used without actually touching the teeth to remove dental biofilm, but no such product exists at this time. Further, the water flow patterns generated by powered toothbrushes do not actually remove biofilm. Dental biofilm must be removed mechanically. Copious water flow in and around the dental biofilm can result in the reduction of endotoxins and can also cause superficial disruption of the dental biofilm surface so that it must recolonize. This may render the biofilm less harmful for a short period of time.
Regardless of whether a brush is powered or manual, it must be used properly for mechanical dental biofilm removal.5 Patient education should be focused on the patient’s needs. If patients do well with a manual toothbrush, there is no reason to switch them to a powered toothbrush or vice versa. It is important to identify problems that patients may have and work with several different products over time to identify what works best.
Even though powered toothbrushes have been proven to more reliably remove dental biofilm and improve gingival health better than manual toothbrushes,6-8 manual toothbrushes are also safe and efficacious. For some patients, a manual toothbrush is best for a variety of reasons, including patient preference. Manual toothbrushes also have collectively been proven to remove plaque and reduce bleeding and gingivitis in clinical trials.4
Dental hygienists have an obligation to be as knowledgeable about the features and advantages (such as requiring the use of less force) of different powered toothbrushes as they are about manual toothbrushes.
Both consumers and professionals are basing their dental and health care decisions on evidence-based information. We have an obligation to research products, to know the standards these brushes have met in testing, and to recommend the appropriate products to meet patient needs.