|Year : 2021 | Volume
| Issue : 1 | Page : 95-100
Comparison of the efficacy of parental brushing using powered versus manual tooth brush: A randomized, four-period, two-treatment, single-blinded crossover study
Pooja Mysore Purushotham1, Arathi Rao2, Srikant Natarajan3, Suprabha Baranya Shrikrishna4
1 Ex-Post Graduate Student, Pediatric & Preventive Dentistry, Manipal College of Dental Sciences, Mangalore (MAHE, Manipal) Light House Hill Road, Mangalore, Karnataka, India
2 Professor, Pediatric & Preventive Dentistry, Manipal College of Dental Sciences, Mangalore (MAHE, Manipal) Light House Hill Road, Mangalore, Karnataka, India
3 Professor & Head, Oral Pathology, Manipal College of Dental Sciences, Mangalore (MAHE, Manipal) Light House Hill Road, Mangalore, Karnataka, India
4 Professor & Head, Pediatric & Preventive Dentistry, Manipal College of Dental Sciences, Mangalore (MAHE, Manipal) Light House Hill Road, Mangalore, Karnataka, India
|Date of Submission||23-Oct-2020|
|Date of Acceptance||03-Mar-2021|
|Date of Web Publication||22-Apr-2021|
Prof. Arathi Rao
Manipal College of Dental Sciences, Manipal Academy of Higher Education, Light House Hill Road, Mangalore - 575 001, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Children <5 years of age need parental assistance with tooth brushing. Purpose: The aim is to compare the efficacy of manual and powered toothbrushes for plaque removal when used by parents to brush their children's teeth. Methods: This randomized, four-period, two-treatment, examiner-blinded, crossover clinical trial comprised children aged 3–5 years. Tooth brushing was performed by the parent using a manual or powered toothbrush. Pre- and post-brushing plaque assessments were performed using the Turesky Modified Quigley-Hein Plaque Index. Differences in plaque scores were calculated using the paired t-test. Results: A significant difference (P < 0.001) in the reduction of the plaque score was observed between the manual and powered tooth brushing groups. Conclusion: Powered toothbrushes performed significantly better than manual toothbrushes in terms of plaque removal when used by parents to brush their child's teeth.
Keywords: Oral health, plaque index, tooth brush
|How to cite this article:|
Purushotham PM, Rao A, Natarajan S, Shrikrishna SB. Comparison of the efficacy of parental brushing using powered versus manual tooth brush: A randomized, four-period, two-treatment, single-blinded crossover study. J Indian Soc Pedod Prev Dent 2021;39:95-100
|How to cite this URL:|
Purushotham PM, Rao A, Natarajan S, Shrikrishna SB. Comparison of the efficacy of parental brushing using powered versus manual tooth brush: A randomized, four-period, two-treatment, single-blinded crossover study. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Aug 2];39:95-100. Available from: https://www.jisppd.com/text.asp?2021/39/1/95/314362
| Introduction|| |
The dental plaque is colonized by various micro-organisms and responsible for the development of dental caries and gingival inflammation in the oral cavity; thus, its removal is vital for the decrease in these activities., Effective tooth brushing plays a crucial role in the removal of accumulated dental plaque. A proper brushing technique along with patient compliance (adequate manual dexterity) is essential for effective tooth brushing.,
Children <5 years of age lack manual dexterity, motivation, and knowledge thereby requiring parental assistance for tooth brushing.
There are two types of toothbrushes: Manual and powered. The powered toothbrush operates via oscillatory, rotatory, or vibratory movements and requires minimal hand movements. On the contrary, a manual toothbrush requires adequate manual dexterity because all the movements are made at the wrist., Parents of very young children face difficulty while using a manual toothbrush.
Several studies have highlighted the importance of powered toothbrushes for self-brushing in children >6 years of age and those with special health care needs; however, very few studies have evaluated the effectiveness of a powered toothbrush on plaque removal when used by the parents to brush their child's teeth.,,,, As per the different studies, powered toothbrushes that employed oscillatory-rotatory movements produced significantly superior plaque removal compared to standard manual toothbrushes.,,,,
The aim of the present study was to compare the efficacy of manual versus powered toothbrushes for the effective removal of plaque when used by parents to brush their child's teeth.
| Methods|| |
This study was designed, analyzed, and interpreted according to the Consolidated Standards of Reporting Trials [CONSORT; [Figure 1]]. It was conducted for 6 months (May–October 2019) at the Department of Pediatric and Preventive Dentistry. This randomized, four-period, two-treatment, examiner-blinded, crossover clinical trial comprised 3–5-year-old children and their parents.
Clearance for the study was obtained from the Ethics Committee of the Institute and uploaded in the Clinical Trial registry. The parents of the children were informed about the aim of the study and the procedures involved using a patient information sheet. Informed consent was obtained from the parents before commencing the study.
Sample size calculation
A sample size of 20 was calculated (95% confidence interval; power, 80%; standard deviation, 0.3) based on the values obtained by Davidovich et al.
The inclusion criteria were as follows: Children aged between 3 and 5 years; both child and parent should be in good general health; and the child should possess a minimum of twelve teeth with scorable surfaces. The exclusion criteria were as follows: Use of systemic antibiotics; children requiring emergency dental treatment; children with known allergies to dyes or any commonly used items; those who received oral prophylaxis within 1 month before the first visit or during the study; and children with space maintainers or any other appliances.
A total of 20 children along with one parent were selected based on the inclusion and exclusion criteria. Each child was randomly selected out of six sequences based on a computer-generated randomization plan: ABBA, BAAB, AABB, BBAA, BABA, and ABAB, wherein A and B indicated powered and manual tooth brushing, respectively. The children were recalled four times (visit 1, 2, 3, and 4) with a wash out period of 48 h between each visit.
Tooth brushing and evaluation
The parents of all the children were instructed to refrain from brushing their child's teeth again or using any other oral hygiene aids after brushing their teeth once in the morning. In addition, the children were required to cease drinking, eating, or chewing gum for 3 h before their appointment, which was given within 5 h after breakfast. The children were not allowed to participate in any other trials during the present study period.
Two evaluators who were blinded to the group allocation evaluated and scored the plaque. The inter-examiner reliability test for the evaluation of the plaque score was conducted on ten patients who were not part of the study and calculated using the Intraclass correlation coefficient.
Colgate® Kids battery-operated toothbrush (Colgate Oral Pharmaceuticals, Colgate-Palmolive company, India), Colgate® Kids 2+ Gentle Soft Toothbrush (Colgate Oral Pharmaceuticals, India), and Colgate® Kids Cavity Protection Toothpaste (Colgate Oral Pharmaceuticals, India) were used in the study.
The parents were provided with details about the method of brushing prior to the study. Their understanding of the brushing method was evaluated by the investigator before beginning the study. In the case of the powered toothbrush, the parents were directed to brush the child's teeth by placing the bristles in position and letting the rotary motion of the brush head perform its function (as advised by the manufacturer). Alternatively, scrub method of brushing was advised while brushing with the manual toothbrush.
The tooth brushing was performed by the parent for 2 min (30 s for each quadrant) using a pea-sized amount of toothpaste per child in front of the examiner during each appointment. The children were instructed to rinse their mouths once lightly with water after brushing. During each visit, the plaque was disclosed using a two-tone disclosing solution (AlphaPlac, Division of The Bombay Burmah Trading Corporation Ltd., Mumbai, India) to obtain the baseline data. Plaque assessments were performed by two examiners who were blinded to the brushing method using the Turesky Modified Quigley-Hein Plaque Index. The plaque was disclosed and the scores were re-evaluated by the same examiners after brushing.
The same procedure was carried out during subsequent appointments using the powered or manual toothbrush that was randomly assigned to each subject.
The criteria for plaque scoring using Turesky Modified Quigley-Hein Plaque Index were as follows: 0, no plaque; 1, separate flecks of plaque present at the cervical margin; 2, continuous band of plaque up to 1 mm at the cervical margin; 3, a band of plaque that is wider than 1 mm but covering less than one-third of the side of the crown of the tooth; 4, plaque covering at least one-third but less than two-thirds of the side of the crown; 5, plaque covering more than two-thirds of the side of the crown.
The buccal and lingual surfaces of each tooth were scored; a total of 40 surfaces on 20 teeth were scored per child. The average values for each child were calculated by dividing the total score by the number of teeth examined.
The primary outcome measure was the difference in plaque reduction before and after tooth brushing, and the secondary outcome was the parents' experience.
SPSS (17.0) version (IBM SPSS® Statistics, IBM Corp:London: UK) (Trial Version) was used to tabulate and analyze the data. The level of significance was set at 5%. Differences between the baseline and postbrushing plaque scores and between obtained after using the powered and manual toothbrushes were calculated using the paired t-test.
| Results|| |
Eighteen mothers and two fathers who brushed their children's teeth at home were enrolled in this study. All the children presented with a complete set of deciduous teeth.
An intraclass correlation coefficient of 0.998 was obtained in the inter-examiner reliability test, which indicated excellent agreement between the two examiners in terms of evaluation of the plaque index [P < 0.001; [Table 1]].
|Table 1: Intraclass correlation coefficient among the two examiners in terms of evaluation of the plaque score|
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A significant difference (P < 0.001) in the reduction of the postbrushing plaque score was observed in both the manual and powered toothbrush groups when compared with their baseline scores. The paired differences between the baseline and postintervention values were 1.52 ± 0.45 (P < 0.001) and 1.54 ± 0.45 (P < 0.001) for examiner one and examiner two, respectively [Table 2].
|Table 2: Comparison of the prebrushing and postbrushing plaque scores in the manual and powered tooth brushing groups using the paired test|
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Furthermore, the powered toothbrushes performed significantly better with a mean difference of 0.45 ± 0.52 (P = 0.001) for examiner 1 and 0.48 ± 0.54 (P = 0.001) for examiner 2 [Table 3].
|Table 3: Comparison of the performances of the manual and powered toothbrushes with regard to the reduction in the plaque score using paired t-test|
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| Discussion|| |
Young children lack good hand-eye coordination and are less consistent with tooth brushing compared to adults., Thus, parental brushing is advised for young children up to 7 years of age. According to the existing literature, powered toothbrushes have proven to be more effective than manual toothbrushes for plaque removal in adults., Studies have shown that rotating or oscillating power toothbrushes are comparatively better than manual toothbrushes when used in adults., Hence, we assumed that powered toothbrushes might prove to be beneficial when used by parents for their young children. To the best of our knowledge, there is no study on the plaque removal efficacy of powered toothbrushes in very young children who require parental assistance to brush their teeth.
The powered toothbrush used in the present study had a small oscillating head that cleaned the teeth and soft bristles to gently sweep away the plaque. This kid's toothbrush had a slim handle and an easy on/off button for easy usability and has been recommended for children over the age of 3 years. The manual toothbrush was designed for kids above 2 years of age. The rounded head and soft bristles of the kids' toothbrush work gently on the developing teeth and molars. The multi-height bristles are specially designed to fit comfortably around small teeth and mouths.
According to the guidelines of the American Academy of Pediatric Dentistry, children aged 3–6 years should use no more than a pea-sized amount of a fluoridated toothpaste. Thus, in the present study, a smear amount of a fluoridated toothpaste (Colgate® Kids Cavity Protection Toothpaste) was used to brush the teeth to maintain standardization.
In the study by Honkala et al., the duration of brushing was found to affect the amount of plaque removal. The standard tooth brushing time used in most studies conducted in children and adults is 2 min. Furthermore, the American Dental Association and the study by Van der Weijden and Slot recommend 2 min as a suitable duration for brushing the teeth of children. Hence, based on these findings, the parents of both groups were instructed to brush the teeth of the children for 2 min in the present study.
A two-tone dye was used to disclose the plaque on the tooth surface. The two-tone dye mixture contains two components (FD and C Red No. 3 and FD and C Green No. 3), which effectively color the “old” plaque blue or blue-purple and “new” plaque red or pink. A red biofilm indicates a newly formed, thin plaque, which is usually located in the supragingival region, whereas a blue biofilm indicates a thicker, older, and more tenacious plaque., The parents who took part in the study were not explained about the significance of the change in the color of the dye to avoid bias because masking of the study participants was not possible.
The Turesky Modified Quigley-Hein Plaque Index is used to evaluate plaque accumulation on the nonrestored buccal and lingual surfaces of the teeth on a scale of 0–5. It was first introduced by G. A. Quigley and J. W. Hein in 1962 and modified by S. Turesky, N. D. Gilmore, and I. Glickman in 1970. An index for the entire mouth is determined by dividing the total score by the number of surfaces examined. The Turesky Modified Quigley-Hein Plaque Index and Rustogi Modified Navy Plaque Index are most commonly used to assess the plaque score in most studies. The Turesky Modified Quigley-Hein Plaque Index reflects the reduction in the area of plaque coverage, whereas the Rustogi Modified Navy Plaque Index indicates the presence or absence of plaque on the tooth surface.
In the present study, significantly increased plaque reduction (81%) was observed following brushing using the powered toothbrush when compared to that using the manual toothbrush (57%). Studies show that electric toothbrushes are more effective for plaque removal than manual toothbrushes when used by children and adolescents., Similar results were obtained in the current study, where powered toothbrushes were found to be more effective than manual toothbrushes in removing the plaque when used by parents to brush their child's teeth.
A significant reduction in the plaque score was observed from the baseline values in both the powered and manual tooth brushing groups. This reduction may be due to various factors, such as the tooth brushing instructions given to the parents before the initiation of the study or the visible layer of plaque due to the application of the disclosing agent, which can facilitate enhanced plaque removal. In addition, the awareness of being observed due to inclusion in the study may have led to the Hawthorne effect among the parents, which might have affected their behavior with regard to tooth brushing technique and the effective removal of the plaque. However, all these factors were common between the two groups; therefore, it is safe to attribute the results of this study to the type of brush used.
All the parents who were included in the present study used the powered toothbrush for the first time and reported that they were easier to use on their children than the manual toothbrushes. Based on this and the outcome of the current study, we can advise parents to use the powered toothbrush to brush their children's teeth.
| Conclusion|| |
Powered toothbrushes performed significantly better than manual toothbrushes with regard to plaque removal when used by parents to brush their children's teeth, and can be recommended for brushing the preschoolers' teeth.
Why this paper is important to Pediatric Dentists?
- Parents of very young children face difficulties while brushing their children's teeth
- In the present study, we found that powered toothbrushes were more effective for plaque removal compared to manual toothbrushes
- Powered toothbrushes may be recommended for use by parents to brush the teeth of their young children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]