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The gloves are off in the oral care aisle. In January the Cochrane Collaboration's Oral Health Group published the largest study ever undertaken on the effects of power toothbrushes and concluded that the majority were no better than a manual brush. The only exceptions were brushes with rotation-oscillation action.
Based at the University of Manchester in England, the Oral Health Group is one of 49 research groups of the Cochrane Collaboration, an international nonprofit organization whose goal is to help consumers and clinicians make well-informed decisions about health care with systematic reviews on the effects of health care measures. Formed in 1992, it is composed of volunteer professionals who use sophisticated analytic techniques to consolidate and assess previous clinical trials.
In its study of powered versus manual toothbrushes, the Oral Health Group analyzed reports on clinical trials of power toothbrushes conducted between 1964 and 2001.
Not surprisingly, response to this study by toothbrush manufacturers was immediate and fervid. Those that make brushes that have rotation-oscillation action sent out press releases informing readers how the study supported their products. In a release from Cincinnati-based Procter & Gamble, for example, Crest global manager of research and development Shekhar Mitra said, "Crest SpinBrush makes rotation-oscillation technology available to everyone at a great value. This independent study only further shows Crest's commitment to providing the best oral care tools at an affordable price."
Boston-based Gillette, which produces the Braun Oral-B power toothbrush, responded similarly. In a statement released Jan. 11—the day the Cochrane study was unveiled—the company used the opportunity to expound on the benefits of its power toothbrush products and to take a shot at its competition: "For over a decade, consumers and the dental community have been bombarded with conflicting information about which type of toothbrushes—manual, power, or 'sonic'—work best," said Oral-B's v.p. of clinical research, Dr. Paul Warren. "This study clears up any confusion and conclusively proves that Oral-B power toothbrush technology is superior in keeping teeth and gums healthy."
Not all responses were as glowing, however. In a release dated Jan. 14, Sonicare maker Philips Oral Care criticized the findings of the Cochrane study, stating that it was an inappropriate assembly of data when taking into consideration the vast technological advancements in power toothbrushes during the past 10 years. "Clearly, power toothbrush technology available in the 1960s was less sophisticated than technology introduced within the last decade, such as the introduction of Sonicare," said principal scientist for clinical affairs Chris McInnes.
"Philips Oral Care does not feel it is appropriate to draw conclusions from the recent Cochrane study on the relative effectiveness of Sonicare because the toothbrush was grouped with 1960s technology in the report and therefore yields an unfair comparison."
The Cochrane Collaboration took issue with the manufacturers. Regarding the Gillette statement, study coordinator William Shaw said that the organization endorsed no products. "While certain toothbrushes manufactured by Gillette do use rotation-oscillation action, other toothbrushes with such action were also included in the review," he said.
The response to the Sonicare press release was harsher, pointing out that side-to-side toothbrushes studied in 1964 compared better against manual toothbrushes than several trials of Sonicare side-to-side action toothbrushes tested after 1990. "When we excluded studies published prior to 1990, the results still failed to detect any benefit provided by toothbrushes with a side-to-side action on plaque or gingivitis when compared to manual toothbrushes," said Shaw.
Notified by Progressive Grocer of Shaw's comment, Philips Oral Health spokesman Pierre Menes defended the company's position. "The Cochrane study limits itself to pre-brushing measures only to assess plaque removal," he said. "In most Sonicare studies, the pre-brushing plaque scores are high because subjects are instructed not to brush for up to 24 hours prior to measurement. Sonicare studies are generally designed to evaluate post-brushing plaque scores, and Sonicare has been clinically proven to remove nearly twice as much plaque as a manual toothbrush."
Nevertheless, the report claims that even on rotation-oscillation devices the reduction of plaque and gingivitis may be borderline for long-term dental health: "Even the 7-percent and 17-percent reductions of plaque and gingivitis we found for rotation-oscillation brushes may be of only modest benefit for dental health." The American Dental Association recommends that only oral care products that can prove a 20-percent improvement be permitted to publish claims for superiority over other products.
Shaw, the study coordinator, criticized the quality of the original clinical trials—many of which were conducted on behalf of the manufacturers themselves—that provided the basis for the Cochrane review. "Systematic reviews such as those prepared by the Cochrane Collaboration consolidate and assess all relevant research, rather than rely on the selective highlighting of one or two research studies or experiences of individuals," he said. "However, the usefulness of such reviews, which examine the findings of previously published studies, depends on the quality of the toothbrush trials upon which every company's marketing claims are based."
But not all available studies were included in the Cochrane report and, as a result, the report's conclusion was not accurate, said Sonicare product marketing manager Jay McCulloch. "We have completed more than 50 studies at 18 universities, studies which were published in magazines or clinical journals," he said. "Of the studies the Cochrane Collaboration looked at, only four involved Sonicare.
The Cochrane Collaboration did not examine studies that lasted less than four weeks, and the bulk of the Sonicare studies, according to McCulloch, were single-brushing studies.
It's how you brush
So who is right? Who is wrong? And, more importantly, does it really matter? According to dentist Ronald Murayama, it is not important whether a person uses a manual or power toothbrush, but rather how the person uses it. "If you know how to use a manual toothbrush, and you use it properly, you can get your teeth as clean as with any other device," he said.
What is particularly interesting about this statement is its source. In addition to being a dentist, Murayama is chairman and c.e.o. of San Juan Capistrano, Calif.-based Amden Corp., which manufactures its own line of power toothbrushes, the Cybersonic and Cybersonic2.
This points to a key factor that may be overlooked in many of the studies—that people may simply enjoy brushing more when they do it with a power toothbrush. That alone may result in better oral health among power toothbrush users, even if clinical trials do not indicate it.
The numbers may help to make that case. While sales of manual toothbrushes are flat or down across the board, according to Chicago-based Information Resources, Inc., sales of power toothbrushes are up, and, in most cases, up significantly. This holds for both rotation-oscillation and side-to-side action brushes, and for all of the major brands, including Oral-B, Sonicare, Crest SpinBrush, and Colgate Motion.
"People tend to brush longer when they have a power toothbrush, because it is fun," said dentist Jennifer Holtzman. "The Cochrane study didn't really examine the compliance issue, the fact that people should be brushing their teeth twice a day for at least two minutes each time. It takes at least two minutes—even with a power toothbrush—to clean the surfaces of the teeth. Brushing teeth with a manual toothbrush is really a technique-sensitive sort of thing. You have to angle your toothbrush 45 degrees and really wiggle those bristles around. The power toothbrushes—whether they are rotation-oscillation or side-to-side action—get the technique stuff out of the way, and that is why they are so fabulous."
Holtzman should know. As executive director of ToothWoman Network, she works to improve oral health through educational programs with special emphasis on women, children, seniors, and people with disabilities. For children, she has created a series of "Big Mouth" games, which are sponsored by Crest, to teach them fun ways to improve their oral health habits.
Most power toothbrush manufacturers are taking the educational approach, including tips on proper brushing technique, especially during the various stages of a child's early years, in hopes that kids will grow up loyal to their brands. And to make brushing interesting for children, manufacturers have developed brushes with licensed cartoon and comic book characters.
Regardless of how the battle plays out when the Cochrane study is updated in two years, manufacturers agree that the supermarket is where the winners will hang their banners. "We see the biggest opportunity in the grocery channel," said Blayne Smith, senior project manager for industry affairs at Procter & Gamble. "The key to this is giving pragmatic suggestions to retailers that will help them to capitalize on growth. Things like splitting the shelf sets 50-50 between manual and power toothbrushes, for example."
With the brouhaha created by the Cochrane study, this seems to be a pragmatic idea, indeed.