P (Population): Special healthcare needs for children and adolescents under 18 years of age.

The objective of this study was to evaluate and compare the efficacy of various oral hygiene aids in the reduction of plaque accumulation and gingival inflammation in children and adolescents with special healthcare needs.

Study population should be children and adolescents under 18 years of age with special healthcare needs with lower age limit of 5 years

Articles reported as an in vitro study or a review article.

Literature search strategy was developed using keywords related to oral health and oral hygiene of special healthcare needs children. Search strategy used for searching articles were Dental plaque AND Special needs AND Children AND Oral health, Mouthwash AND Special needs AND Children AND Oral hygiene, Toothbrush AND Special needs AND Children AND Oral hygiene with such various combinations. Data were searched through PubMed, Google Scholar, Cochrane, Scopus, ProQuest, and Web of Science from January 1, 2000, and December 31, 2023. Cross references, gray literature, and hand searching of articles were done when full texts of relevant studies were not available through electronic databases.

Two review authors (VS and SMH) independently screened the titles, abstracts, and full texts and included them if they met the inclusion criteria. All the excluded studies were recorded with their reason for exclusion [Figure 1].

The risk of bias for individual study included was assessed using the ROBVIS (Risk-of-bias Visualization) tool where 5 domains were assessed and were categorized as high, medium, or low risk accordingly.^[9] All included studies had low-to-moderate risk of bias with all respected domains. Among the included studies, Patel et al., Sinha et al., Stefanini et al., and Chibinski et al. reported the lowest risk of bias,^[10-13] wereas Dogan et al., Fageeh et al., Jaya et al., Krishnan et al., and Sharma et al. reported the highest risk of bias.^[5,14-17] Summary about each risk of bias item presented as percentages across all included studies is mentioned [Figure 2].

For quantitative measures, 23 articles were reviewed and 11 were selected for meta-analysis. These 11 articles were statistically evaluated using statistics and data software (STATA) using the random effects model. 11 articles selected for meta-analysis had the same comparator and intervention and the objectives of these articles aligned with the objectives of this systematic review ensuring consistency with the results and aim of this review. Meta-analysis was divided into 2 parts (mechanical and chemical oral hygiene aids) for plaque control used in children with special healthcare needs.

In mechanical oral hygiene aids, 9 studies containing data on 317 patients, evaluated the effectiveness of novel (which included powered or electronic toothbrushes and customized toothbrushes) versus manual toothbrushes in terms of reduction in PI as an outcome.^{[10,11,15,18-23]} Forest plots showed pooled estimates favoring the novel toothbrushes group. This signifies that reduction in PI on average is 4.23 times more by novel toothbrushes as compared to manual toothbrushes and this difference is statistically significant (P = 0.01). I² statistic showed 99.63%, heterogeneity for Tau² was 26.45, and overall effect for Z value being −2.45 (P = 0.01) [Figure 3].

Four studies containing data on 123 patients, evaluated the effectiveness of novel versus manual toothbrushes in terms of reduction in gingival inflammation as an outcome.^{[18,20,21,23]} Forest plot showed pooled estimates favoring novel toothbrushes but the results were not found to be statistically significant (P = 0.13). I² statistic showed 99.80%, heterogeneity for Tau² was 106.16, and overall effect for Z value being 1.53 (P = 0.13) [Figure 4].

In chemical oral hygiene aids, 2 studies containing data on 41 patients, evaluated the effectiveness of CHX spray versus placebo spray in terms of reduction in PI as an outcome.^[13,24] Forest plot showed pooled data in favor of the CHX group but was not statistically significant. I² statistic showed 96.95%, heterogeneity for Tau² was 71.52, and overall effect for Z value being −1.58 (P = 0.11) [Figure 5].

Certainty of evidence: Summary of findings based on the GRADE approach. In the present review, the outcome of PI and GI when novel mechanical oral hygiene aids are used and the outcome of PI when CHX is used is moderate [Table 2].

Mechanical oral hygiene aids included are manual, powered, or electric and customized toothbrushes, toothbrushes for special healthcare needs such as Collis curved, nano-enabled, and triple-headed toothbrushes. While chemical oral hygiene aids include CHX in the form of spray.

Removal of mechanical plaque with the help of manual toothbrushes remains one of the most commonly used aids and is a primary method of cleaning the teeth.^[27] The major advantages of manual toothbrushes are that it is inexpensive, more flexible, and easily available; however, this brush is inconvenient for special needs children and adolescents.^[28] In Literature, Aulia et al. found that children with Down’s syndrome were unable to adapt to electric toothbrushes as they found the sounds and vibrations of electric toothbrushes to be uncomfortable and were scared of using them.^[29] Similarly, Vasta et al. also concluded that both manual and powered toothbrushes are equally effective in reducing plaque and gingival inflammation in compromised patients.^[27] Studies by Silva et al. on Down’s syndrome and Ferraz et al. on cerebral palsy children also concluded similar efficacy of manual and powered toothbrushes.^[19,24] Systematic reviews by Colman et al. and Kalf Scholte et al. gave low levels of confirmatory results and evident differences between the effectiveness of powered and manual toothbrushes.^[30,31]

Powered toothbrushes do not require specific brushing techniques, have better accessibility in interproximal tooth surfaces, and require lesser force than manual toothbrushes.^[32] These toothbrushes are attractive looking which helps motivating special needs children and thus improving oral hygiene.^[19] Karimi et al. stated that powered toothbrushes are indicated for children with mental or physical disability owing to their ease of usage.^[28] Systematic review by Graves et al. concluded that electric toothbrushes have better efficacy than manual toothbrushes for children aged between 2 and 17 years.^[33] These results are similar to our systematic review, however, this review by Graves et al. was conducted on normal healthy children. Similarly, Rosing et al. highlight that powered toothbrushes have better plaque removal efficacy than manual toothbrushes for people with special healthcare needs.^[34]

In literature, studies conducted on children with special healthcare needs by Dogan et al., Bozkurt et al., Stefanani et al., Jaya et al., Shrama et al., Cui et al., Ferraz et al., Jamkhande et al., Malthi Sree et al., and Vajawat et al. also concluded that powered toothbrushes have better efficacy when compared to manual toothbrushes in reducing plaque accumulation and gingival inflammation.^{[5,7,12,15,17,21-23,35,36]} In the current systematic review, results favored more toward usage of novel mechanical oral hygiene aids for plaque reduction and reduction in gingival inflammation. Results were found to be statistically significant when plaque scores were evaluated for novel versus conventional mechanical aids (P = 0.01). However, when comparison for gingival inflammation reduction was done, the results favored novel mechanical oral hygiene aids but were not found to be statistically significant (P = 0.13).

Customized handle toothbrushes are so named as they are basically conventional toothbrushes with enlarged handle customized according to each individual. Since children with special healthcare needs lack motor coordination, it becomes difficult for them to perform acts like toothbrushing for which they need to depend upon their caretakers.^[37] By use of this toothbrush, it is emphasized that special needs people can maintain their own oral hygiene without depending on their caretakers thus improving their self-esteem and self-dependency. With this, it also helps in improving the muscular coordination of people with special healthcare needs.^[18]

Studies by Droubi et al. and Rai et al. concluded that customized toothbrushes can significantly improve oral hygiene when compared to conventional manual toothbrushes in children with cerebral palsy and Down’s syndrome, respectively.^[18,20] Study by Paisag et al. on cerebral palsy children concluded that customized toothbrushes not only improved oral hygiene but also reduced halitosis in these children.^[37] In the current systematic review, although customized toothbrushes have not been evaluated separately but have been included as a part of novel mechanical oral hygiene aids and results favor the use of customized handle toothbrushes for reducing plaque and gingival inflammation.

Collis curved or curved bristle toothbrushes have a better range of motion and thus are indicated to be used in people with special needs. Studies by Faghee et al., William et al., and Chava et al. stated that the plaque removal efficacy of these toothbrushes is higher than conventional toothbrushes.^[14,38,39]

Nano-enabled brushes are incorporated with nanoparticles, coated with charcoal and gold particles, and have antimicrobial properties.^[40] These brushes are manual, can be easily used by people with special needs with least training, and are less expensive as compared to electric toothbrushes.^[15] Studies by Faghee et al., Jaya et al., and Pravithra D et al. concluded that nano toothbrushes have greater plaque removal efficacy and less microbial contamination as compared to manual toothbrushes.^[14,15,41]

Triple-headed brushes are modified brushes with triple heads designed to clean buccal, lingual, and occlusal surfaces and thus are indicated in people with special needs.^[5] Studies conducted by Olivera et al. and Youcharoen et al. have proved that triple-headed toothbrushes are more efficacious in plaque removal as compared to manual toothbrushes.^[42,43] Systematic review by Kalf Scholte et al. concluded that the use of triple-headed might be favorable with respect to plaque removal when brushed by a caregiver.^[44] However, abovementioned studies were conducted on normal children. Study conducted by Dogan et al. and Sauvetre et al. on mentally disabled group of children favored the use of triple-headed toothbrushes over manual toothbrushes with better plaque removal efficacy.^[5,45]

Interdental aids can be used as an adjunct to regular toothbrushing for better plaque removal.^[32] In this review, only 1 study has reported the use of interdental aids such as floss and oral irrigators in visually impaired children and has concluded that electrically driven oral irrigators can remove plaque better when used with toothbrushing.^[46]

Chemical plaque control agents have proven to be an ideal adjunct to mechanical oral hygiene aids.^[32] Literature has thus established the fact that CHX mouthwashes are “gold standard” and can be one of the best chemical plaque removal aids in disabled people.^[7] CHX is a cationic bisbiguanide effective against an array of microorganisms, including Gram-positive and Gram-negative organisms. CHX prevents plaque accumulation by preventing pellicle formation, adsorption of bacterial cell walls onto tooth surfaces, and binding of mature plaque by precipitating agglutination factors in saliva and displacing calcium from the plaque matrix.^[32]

Systematic review by Colman et al. concluded the use of CHX as an effective adjunct to toothbrushes but could not give clear evidence with the mode and concentration by which it should be used.^[30] Ferreira et al. concluded that early introduction in periodontal care, participation of parents, frequency of attendance, and association with chemical adjuvants seem to improve periodontal outcomes in the preventive and periodontal treatment of Down’s syndrome patients.^[47] However, this review could not conclude which agent should be best used and with what concentration. Even though our systematic review favored the use of 0.12% CHX spray, this result was not found to be statistically significant (P = 0.11) stating that CHX can be used as an adjunct to mechanical oral hygiene aids in the maintenance of oral hygiene and plaque reduction.

In the present systematic review and meta-analysis, only 1 study evaluated and compared the efficacy of low-fluoridated and calcium phosphate-based dentifrice formulations when used with powered and manual toothbrushes in children with autism. This study concluded that calcium sucrose phosphate dentifrice with powered toothbrushes in children lacking manual dexterity can be used as a better alternative to low-fluoridated dentifrice formulations.^[48] Similarly, only 1 study talks about herbal mouthwash being an effective alternative to CHX mouthwash for reducing plaque in visually impaired children.^[49] Moreover, a study by Deshpande et al. evaluates the use of Triphala tooth wipes in plaque reduction being effective for children with intellectual disability.^[50]

During the literature search for our systematic review, we found that although several studies were conducted in the span of 2000–2023, the majority of these studies have not considered the severity of the condition of special children and its effects on oral health. A very few studies have been conducted on children with hearing impairment. Heterogeneity observed between studies might have resulted from different methodologies followed, study designs and small sample sizes in individual studies. Further high-quality long-term randomized controlled clinical trials of more than 6-month follow-up and a larger sample size is recommended.

Studies on the utilization of herbal products for children with special healthcare needs are required and its effects on oral health can be a future implication of this systematic review.

Nil.

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.