***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To assess the plaque removing efficacy and safety of a novel manual toothbrush ( Oral-B Pulsar-PUL ) compared to leading manual and battery toothbrushes . METHODOLOGY Three clinical studies were conducted , each having a r and omized , examiner-blind , crossover design . Study 1 compared PUL to a newly marketed manual toothbrush , Colgate 360 degrees ( COL ) , Study 2 compared PUL to the Oral-B Advantage Plus ( AP ) and Oral-B CrossAction ( CA ) manual toothbrushes , and Study 3 compared PUL to two battery toothbrushes , Oral-B CrossAction Power ( CAP ) and Crest SpinBrush Pro ( SBP ) . Before each brushing visit , subjects refrained from all oral hygiene procedures for 23 - 25 hours , received an oral tissue examination , and pre-brushing plaque was scored based on the Rustogi et . al , odified Navy Plaque Index . After subjects brushed with the assigned toothbrush in their usual manner for one minute , oral tissues were then re-examined and post-brushing plaque scores recorded . Subjects with pre-brushing whole mouth mean plaque scores > or = 0.6 continued in the study after the first visit . Following a brief washout period between additional visits , the above procedures were repeated in the remaining treatment periods . The examiners who made all clinical measurements were blinded to the treatment sequence . RESULTS All toothbrushes significantly ( p = 0.0001 ) reduced plaque levels from all areas after a single brushing . Study 1 showed a significant difference for PUL in all areas , whole mouth , margin , and approximal ( p < 0.05 ) compared to COL . In Study 2 , PUL removed significantly more whole mouth ( p < 0.01 ) and approximal plaque ( p < 0.005 ) than AP as scored by two examiners , but did not show a significant advantage versus CA . In Study 3 , PUL removed significantly more plaque than CAP and SBP for whole mouth ( both p = 0.0001 ) , marginal ( both p = 0.0001 ) , and approximal ( p < 0.005 , p = 0.0001 , respectively ) areas . All toothbrushes were found to be safe with no evidence of hard or soft tissue trauma . CONCLUSION The new Oral-B Pulsar toothbrush removed significantly more plaque than Colgate 360 and Oral-B Advantage Plus . Additionally , Pulsar removed significantly more plaque than two battery brushes , Oral-B CrossAction Power and Crest SpinBrush Pro This single-blind , 8-week study compared the efficacy of a sonic toothbrush and a manual brush in 40 patients with adult periodontitis . Qualitative clinical indices and quantitative laboratory methods were used to monitor the periodontal status of 3 pockets 5 to 7 mm deep in each subject . Patients were r and omly assigned either a sonic or manual toothbrush . The two groups were comparable with respect to age , gender , and anatomical location of the test sites . Data were collected from all sites at baseline and at 2 , 4 , and 8 weeks . Over the 8-week period , both groups showed significant improvements in the clinical indices used . Descriptive statistics indicated the sonic brush group had greater improvement than the manual group in the clinical parameters ( gingival index , bleeding index , probing depth , and clinical attachment level ) . Gingival crevicular fluid ( GCF ) flow was significantly lower in the sonic brush group ( P = 0.018 ) . Considerable variation was present in the levels detected for both inflammatory cytokines tested , however , concentration of interleukin-1 beta was significantly lower in the GCF of sonic group patients ( P = 0.05 ) , while concentration of interleukin-6 was significantly reduced in both groups ( P < or = 0.05 ) ( t tests ) . Under these conditions , there is some evidence to suggest that the sonic toothbrush is more beneficial in resolving inflammation in patients with moderate periodontal disease The aim of this study was to compare the efficacy of an ionic and a conventional toothbrush in reducing  gingival inflammation  measured by gingival crevicular fluid ( GCF ) volume .  Twenty dental students participated in this r and omized crossover clinical trial . Quigley-Hein ( QH ) Plaque Index was assessed in six sites per tooth . GCF was measured in 3 teeth . Two experimental periods of 28 days with a 14-day washout were set . Mean values of GCF were calculated and tested by paired sample t-test . Correlations between % QH = O and alterations in GCF were performed . No significant differences were observed between conventional and ionic toothbrushes respectively neither at baseline ( .62 + /- .19 vs. .55 + /- .18 ) nor at 28 days ( .44 + /- .12 vs. .47 ) . A negative correlation ( -.33 ) was detected between the increase in % of QH = O and GCF for both brushes . It may be concluded that the performance of an ionic toothbrush does not differ from that of a conventional brush AIM To evaluate gingival recession changes after six months of brushing with an oscillating-rotating power toothbrush ( PT ) or an ADA reference manual toothbrush ( MT ) . METHODS AND MATERIAL S Healthy subjects with pre-existing recession were assigned to brush with either a PT ( n=55 ) or an ADA reference MT ( n=54 ) according to a prospect i ve r and omized , controlled , single-blind , parallel group design . Participants were asked to brush their teeth twice daily for two minutes each with the same fluoride toothpaste . Clinical attachment loss and probing pocket depths ( PPDs ) were measured at six sites per tooth to the nearest mm by one calibrated examiner at baseline and after six months . Gingival recession was calculated as the differences between clinical attachment loss and PPDs overall and separately at individual sites . RESULTS As compared with baseline , overall recession at six months was reduced from 2.35 + /- 0.35 mm to 1.98 + /- 0.55 mm ( p<0.001 ) in the PT group and from 2.26 + /- 0.31 mm to 1.90 + /- 0.45 mm ( p<0.001 ) in the MT group . The data showed 40 % ( power ) and 38 % ( manual ) of all recession sites improved by at least 0.5 mm while 51 % and 54 % remained unchanged . Eight percent and 7 % recessions increased over time . Differences between groups were not statistically significant at either timepoint . CONCLUSION Both the PT and the MT significantly reduced pre-existing gingival recession after six months of brushing . This may have been due to improved brushing technique ( i.e. , Hawthorne effect ) . CLINICAL SIGNIFICANCE Based on these six-month data , concern that power tooth brushing results in a higher risk for gingival recession is not warranted PURPOSE Recently , a  power toothbrush ( Crest SpinBrush )  has been reported to remove plaque more effectively than a manual toothbrush ( Colgate Navigator ) . The objective of these studies was to compare the plaque removal efficacy of two control manual toothbrushes ( Colgate Wave and Colgate Plus ) to an experimental power toothbrush ( Crest SpinBrush ) . The Colgate Plus has an ordinary flat bristle trim design , while the Colgate Wave has an advanced design multilevel bristle trim for greater interproximal penetration . MATERIAL S AND METHODS Each of these two studies were r and omized , controlled , examiner-blind , 4-period crossover design s which examined  plaque removal with the experimental toothbrush relative to a control manual toothbrush following a single use in 37 and 35 subjects , respectively .  Plaque was scored before and after brushing using the Turesky Modification of the Quigley-Hein Index . RESULTS In the first study , average baseline plaque scores were 2.88 and 2.89 for the experimental toothbrush and advanced design ed manual control toothbrush ( Colgate Wave ) treatment groups , respectively . With respect to all surfaces examined , the experimental toothbrush delivered an adjusted ( via analysis of covariance ) mean difference between baseline and post-brushing plaque scores of 0.70 while the control toothbrush delivered an adjusted mean difference of 0.59 . The difference between the brushes was statistically significant ( P < 0.001 ) . The experimental toothbrush removed , on average , 19.9 % more plaque than the control toothbrush . In the second study , baseline plaque scores averaged 3.07 and 3.04 for the experimental toothbrush and ordinary flat trim manual control toothbrush ( Colgate Plus ) treatment groups , respectively . With respect to all surfaces examined , the experimental toothbrush delivered an adjusted ( via analysis of covariance ) mean difference between baseline and post-brushing plaque scores of 0.87 while the control toothbrush delivered an adjusted mean difference of 0.62 . The difference between brushes was statistically significant ( P < 0.001 ) . The experimental toothbrush removed , on average , 40.0 % more plaque than the control toothbrush The aim of the present study was to evaluate the efficacy of manual and electric toothbrushes in plaque control in periodontal patients after proper instructions . Thirty six periodontal patients ( mean age of 49 years , 21 females and 15 males ) were included and completed the study ( 100 % compliance ) . A single-blinded , r and omized , controlled , cross-over clinical design was adopted , with the patients using during 2 periods of 14 days each the manual and /or electric toothbrush .  Four subgroups of 9 individuals were studied : A1 - -used manual toothbrush in both experimental periods ; A2 - -used the manual toothbrush during the first period and the electrical toothbrush during the second period ; B1 - -used electrical toothbrush during both periods ; B2 - -used the electrical toothbrush in the first period and the manual one in the second period . Brushing was performed during 14 days and at day 14 and 28 it was performed in the clinic , and timing of brushing was recorded without patients being aware . The Plaque Index ( Silness , Löe , 1964 ) was used . Intra-group comparisons were performed by paired t-test and inter-group comparisons by independent sample t-test , with an alpha level of 0.05 . The results showed no difference between the tested brushes neither for plaque nor for timing . However , re-instruction was detected as an important factor , since for all groups the second period , after reinstruction , showed lower plaque scores . It is concluded that professional advice and instruction and re-instruction seem more important in order to obtain good plaque control than the choice of toothbrush in subjects with periodontal disease PURPOSE To evaluate the efficacy of a novel multi-directional power toothbrush in reducing plaque and gingivitis relative to a st and ard manual toothbrush control . METHODS This 4-week , r and omized and controlled , single-center , parallel group , examiner-blinded clinical study enrolled adults with mild-to-moderate gingivitis . At baseline , pre-treatment gingivitis and plaque levels were assessed via the Lobene Modified Gingival Index ( MGI ) , the Gingival Bleeding Index ( GBI ) , and the Rustogi Modified Navy Plaque Index ( RMNPI ) . Subjects qualifying were assigned r and omly to one of two toothbrush groups : a novel multi-directional power toothbrush ( Oral-B Professional Deep Sweep TRICLEAN 1000 , also marketed as Oral-B TriZone ) or a st and ard soft manual control toothbrush . Aside from a supervised brushing at baseline on-site , subjects brushed at home twice daily with their assigned test brush . After 1 week , subjects returned for RMNPI plaque evaluations . At Week 4 , subjects were again recalled to evaluate toothbrush efficacy , and received MGI and GBI gingivitis and RMNPI plaque evaluations . RESULTS 119 evaluable subjects completed the study . Both the novel power and manual control toothbrushes yielded statistically significant ( P < 0.001 ) mean plaque reductions compared to baseline at Weeks 1 and 4 ( except Week 1 manual brush gingival margin ) and significant mean MGI and GBI gingivitis reductions ( P < 0.001 ) . Comparing the relative effectiveness of the test brushes , the novel multi-directional power brush produced significantly superior anti-gingivitis and anti-plaque reductions compared to pre-treatment relative to the manual control brush in every analysis at both time points . The Week 4 adjusted mean relative reductions favoring the multi-directional power brush were 3 and 1.49 times greater for whole mouth MGI and GBI , respectively ( P < 0.001 ) ; and were 2.1 , 4.7 and 2 times greater for the RMNPI whole mouth , gingival margin and interproximal regions , respectively ( P < 0.001 ) . Both toothbrushes were well-tolerated Twelve dentulous patients , age 65 or older , with no medical or pharmacologic predisposition to gingival hyperplasia were enrolled in a controlled clinical trial to evaluate the effect of the unaided use of an ultrasonic toothbrush on supragingival plaque and gingival bleeding . Subjects used the ultrasonic toothbrush in lieu of their conventional toothbrushes for a 30-day period . Clinical measurements of the plaque index and bleeding index were made at baseline and at 15 and 30 days . At the end of the 30-day test period , the use of the ultrasonic toothbr 
    Output:
    
Powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term .
The clinical importance of these findings remains unclear .
Any reported side effects were localised and only temporary