Powered vs. manual toothbrushes in fixed orthodontic patients: a systematic review and meta-analysis

Background: The benefits of powered toothbrushes (PTBs) over manual toothbrushes (MTBs) are well established. However, for orthodontic patients with fixed appliances (FAs), the evidence remains diverging. Moreover, direct comparisons between PTBs with different action modes and MTBs in terms of plaque and gingivitis control are limited. With new data emerging, an updated synthesis of the literature, including subgroup analysis by PTB action mode, is warranted. 

Objectives: To determine the efficacy of PTBs vs. MTBs in orthodontic patients with FAs on reducing plaque scores (PS), gingivitis scores (GS) and gingival bleeding scores (BS). 

Search Methods: PubMed-MEDLINE and Cochrane-CENTRAL were searched until November 2025, and the reference lists of eligible studies were manually reviewed. 

Selection Criteria: Controlled clinical trials (CCTs) or randomized controlled clinical trials (RCTs); involving orthodontic patients with buccal FAs, toothbrushing performed by participants in good general health; comparing PTBs and MTBs; reporting PS, GS, and BS. 

Data Collection and Analysis: From the included papers, data of interest were extracted, risk of bias was evaluated by RoB 2 or ROBINS-I, and a descriptive analysis was performed. Where possible, meta-analyses were performed with subgroup meta-analyses by evaluation index or/and PTB action mode, along with heterogeneity evaluation, publication bias assessment, sensitivity analysis and trial sequential analysis. The evidence quality and effect sizes were assessed, and, where appropriate, the strength of recommendations was rated. 

Results: Twenty-three papers (including 39 comparisons) were eligible, with low-to-high risk of bias and considerable heterogeneity. Descriptive analysis found no overall difference in most comparisons for PS (64%), GS (76%), and BS (75%). Incremental-difference meta-analyses indicated PTBs had medium effects over MTBs on PS [standardized mean difference (SMD) = −0.77, 95% confidence interval (CI): −1.33 to −0.21, P =.007, I² = 92%], large effects on GS (SMD = −0.82, 95% CI: −1.55 to −0.09, P =.03, I² = 93%), and medium effects on BS (SMD = −0.51, 95% CI: −0.88 to −0.13, P =.008, I² = 80%). All sensitivity analyses confirmed PTB benefits for BS, with RCT-restricted analyses supporting improvements for PS and GS. Publication bias could not be excluded for any incremental-difference meta-analyses, and evidence quality was low across all parameters. In subgroup meta-analyses by PTB action mode, counter-rotational PTBs (CR-PTBs) showed large effects on PS (very low-quality evidence). 

Conclusion: For fixed orthodontic patients, low-quality evidence limited by methodological weaknesses and inconsistency suggests PTBs may moderately improve PS compared with MTBs, with medium to large effects on gingival parameters. Subanalysis by action-mode showed that only CR-PTBs provided large improvements in PS over MTBs, supported by very low-quality evidence. The findings observed in this systematic review are sensitive to a limited number of studies and should be interpreted cautiously, as true effects remain uncertain and may change with more robust randomized evidence.