COMPARISON OF POWERED TOOTHBRUSH WITH OR WITHOUT

ORIGINAL ARTICLE
COMPARISON OF POWERED TOOTHBRUSH WITH OR WITHOUT
PARENTAL ASSISTANCE WITH MANUAL TOOTHBRUSH ON
PLAQUE AND GINGIVITIS IN MENTALLY CHALLENGED
CHILDREN OF 12-18 YEARS IN PUNE, INDIA.
Amol Jamkhande1
Sahana Hegde-Shetiya2
Ravi Shirahatti3
MDS
MDS
MDS
OBJECTIVE: To compare the effects of powered toothbrush with or without parental assistance and manual
toothbrush on plaque and gingivitis in 12-18 yr old mentally challenged children.
METHODOLOGY: The study was conducted in Kamayani School for Mentally Challenged, Pune, India having
IQ level 50-69. A total of 45 subjects were selected and randomly allocated, 15 in each of the following 3 study
groups; Manual toothbrush, Powered toothbrush and Powered toothbrush with parental assistance. The Gingival
Index (GI) and Turesky- Gilmore- Glickman modification of Quigley Hein Plaque Index (TQHPI) were used.
Examination was done at 0,15 and 30 days after the use of respective interventions. ANOVA, ANCOVA, Post-hoc
Bonferroni and Post-hoc tukey test were used for statistical analysis.
RESULTS: Powered toothbrush with parental assistance significantly reduced plaque levels whereas Powered
toothbrush significantly reduced gingivitis than manual toothbrush.
CONCLUSION: Powered toothbrush was more effetve than manual toothbrush in reducing gingivitis.
KEYWORDS: Powered toothbrush, Manual toothbrush, Quigley Hein Plaque Index, Gingival Index.
How to cite this article:
Jamkhande A, Hedge-Shetiya S, Shirahatti R. Comparison of powered toothbrush with or without parental assistance
with manual toothbrush on plaque and gingivitis in mentally challenged children of 12-18 years in Pune, India. J
Pak Dent Assoc 2013;22(1):42-46.
necessary to satisfactorily use a toothbrush3. It has been
suggested that complete plaque removal with a conventional
toothbrush is not realistic for this group2. For these reasons,
studies were directed at developing new toothbrushes to
improve effective plaque removal. In the past few years
much has been written, discussed and claimed about the
use of powered toothbrushes, with or without comparison
to other types of toothbrushes.
Comparisons of the use of powered and manual
toothbrushes have been reported in several articles4,5,6,7.
The majority of investigations indicate that both types of
brushes are equally effective used by handicapped or
average individuals. Several other studies6,7 suggest that
powered toothbrushes show statistically significant
superiority to manual brushes in removing plaque.
Comparing the effects of electric and manual brushing,
the results seem to vary depending on whether or not
instruction of use is given. It has been suggested that
children’s dental health would be improved with parental
involvement. Bullen et al8 found that children whose
mothers had strongly positive attitudes about them had
INTRODUCTION
T
he mentally challenged patient presents a special
challenge to the dental health care team. It is generally
acknowledged that majority of these children have been
dentally neglected1. They are generally incapable of
obtaining an adequate oral hygiene level by manual brushing
because of their limited motor skills, lack of knowledge
about oral hygiene and effective brushing, and reduced
amount of time spent brushing their teeth2.
Many times they have the ability to coordinate
movements, but cannot adjust to the mental gymnastics
1 Assistant Professor, Department of Public Health
Dentistry, Bharati Vidyapeeth Deemed University
Dental College and Hospital, Katraj, Pune, India.
2 Professor and Head, Department of Public Health
Dentistry, Dr. D.Y.Patil Vidyapeeth's, Dr. D.Y. Patil
Dental College and Hospital, Pimpri, Pune, India.
3 Reader, Department of Public Health Dentistry,
Sinhagad Dental College and Hospital, Pune, India.
Correspondence: Dr. Amol Jamkhande<[email protected]>
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Jamkhande A/ Hedge-Shetiya S/ Shirahatti R
Comparison of powered toothbrush in mentally challenged children
syndrome or epilepsy, and/or on long term medications
like Dilantin Sodium or any other which could influence
their oral status and subjects undergoing fixed orthodontic
therapy were excluded. Ethical clearance was obtained
from Institutional Ethics Committee before commencement
of the study. Pilot study was conducted for 1 week with
2 subjects in each of the 3 groups to know the feasibility
of the study. Results were not included in the main study.
The Gingival Index (GI)12 by Loe and Silness was
recorded which was followed by Turesky- GilmoreGlickman modification of Quigley Hein Plaque Index
(TQHPI) 13 . ‘Plaksee’ disclosing solution containing
erythrosine was used to disclose plaque before recording.
Calibration of the investigator was done and a double blind
trial was carried out. The dentifrice used by the study
subjects was Colgate Total 12 which contained 1000 ppm
of fluoride. Oral hygiene instructions were given and
brushing technique was demonstrated for brushing with
the manual toothbrush without parental assistance. For the
powered toothbrushes these instructions followed the
manufacturer’s recommendations. Brushing time was
instructed as 2 minutes each time twice a day. Pea size
amount of toothpaste was instructed to be dispensed on
the toothbrush for which a demonstration was given to the
subjects and their parents. Compliance was checked with
the help of a reminder sheet to be filled by the subject or
his/her parent daily after brushing. These compliance sheets
were checked weekly by the respective class teachers and
by the investigator during subsequent examinations.
Subjects whose compliance was less were reinforced with
oral hygiene instructions during subsequent examinations.
No adverse effects were noted on the oral tissues. All the
toothbrushes and toothpastes were provided to the study
subjects free of cost during the entire duration of the study
by the investigator. Recording of Indices was done on 0,
15 and 30 days and all records were maintained in a record
chart.
Statistical Analysis: Statistical analysis was done using
the SPSS version 10.0. Individual and group mean values
and standard deviations were calculated along with the
percentage reduction in the scores. Level of significance
was set at 0.05. Statistical analysis was done using ANOVA
& ANCOVA test to check for significant differences in
between the means of the plaque and gingival index at 0,
15 and 30 days and also for comparisons in between the
3 groups in reduction of plaque and gingivitis. If ANOVA
results were significant then Post-hoc tukey test was used
for intergroup comparison between 0-15 days and 0-30
days. Similarly if ANCOVA results were significant then
better oral hygiene and less caries.
In our search of the literature we came across many
studies4,5,6,7. comparing the use of manual and powered
toothbrush but there was no study found which compared
the use of manual and powered toothbrush with parental
assistance in mentally challenged children. In this curiosity
of finding the influence of using powered toothbrush with
parental assistance in mentally retarded children, this study
was conducted.
So the study was aimed to compare the effects of using
powered toothbrush with and without parental assistance
with manual toothbrush on plaque and gingivitis in mentally
challenged children of 12-18 yrs age group.
MATERIALS AND METHODS
The study was conducted in Kamayani School for
Mentally Challenged, Pune, India. The subjects were
selected from age group 12-18 yrs with IQ level – 50-69
(mild mental retardation)9 according to school medical
records.
ADA Type III clinical examination was done10. Simple
random sampling by lottery method was followed. Sample
size comprised of total 45 subjects (Fig 1), 15 in each
group, in accordance to the American Dental Association
acceptance program clinical study guidelines for
toothbrushes11. The 3 groups were; A – Manual toothbrush
(MTB) - (Colgate Sensitive toothbrush), B – Powered
toothbrush (PTB) - (Colgate Motion toothbrush) and C
– Powered toothbrush with parental assistance (PTBA) (Colgate Motion toothbrush). –Parents/guardians who gave
an informed consent, subjects in the age group of 12-18
yrs with IQ level ranging from 50-69, having fair and
poor gingival and oral hygiene index scores and a score
>1 for plaque index were included in the study. Subjects
suffering from chronic debilitating conditions like Down’s
JPDA Vol. 22 No. 01 Jan-Mar 2013
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Jamkhande A/ Hedge-Shetiya S/ Shirahatti R
Comparison of powered toothbrush in mentally challenged children
Post-hoc Bonferroni test was used for intergroup were of 16-18 year age group. Compliance for brushing
comparison between the 3 groups at 15 & 30 days. frequency was 98%, 99% and 99.1% in the groups A, B
and C respectively during the study period. There was no
significant difference seen in the mean scores of the TQHPI
RESULTS
and GI at 0 days, so they were considered homogenous at
baseline. In group A though the TQHPI scores showed a
Table 1 – Comparison between 3 groups & their means
decreasing trend over the study period it was found to be
for TQHPI at 0, 15 and 30 days.
statistically significant only at 0-30 days (Table 1), but the
reduction in GI scores was significant from both 0-15 and
0-30 days (Table 2). In groups B and C the reduction in
TQHPI (Table 1) and GI (Table 2) scores were significant
from 0-15 and 0-30 days. For TQHPI, ANCOVA at 15 and
30 days shows that there is a significant difference between
groups A and C (Table 1). For GI, ANCOVA at 30 days
shows that there is a significant difference between groups
A and B (Table 2).
DISCUSSION
The results of this study show that plaque and gingival
scores improve when mild mentally retarded children who
are able to perform toothbrushing themselves or with
parental assistance are provided powered toothbrushes. In
group A the reduction in gingivitis was significant (p<
0.01) over a period of 15 and 30 days. This result is in
contrast with that obtained by Bratel et al14 where reduction
Table 2 – Comparison between 3 groups & their means in gingivitis was not seen. The plaque levels too showed
a trend towards reduction which was statistically significant
for GI scores at 0, 15 and 30 days.
only at 30 days. These reductions could be attributed to
the increased frequency of brushing after subjects were
included in the study.
In group B and C the reduction in plaque was significant
at 15 and 30 days when compared to group A. This may
be attributed to the ‘novelty effect’ or gadget appeal of the
powered toothbrushes. The reduction of plaque index
scores was significant (p<0.05) in group B and C over the
15 day period when compared to manual toothbrush group.
Similarly greater reductions were seen in studies conducted
on populations with a different age group 2,4,15,16,17-23.
The reduction of the GI score was significant in all
groups at 15 and 30 days as compared to plaque. A reduction
in gingivitis can be measured more objectively where as
plaque accumulation depends on subjective variations on
the day of the examinations to a larger extent.
The results of the group with “Powered Tooth Brush
Used with Parental Assistance” do not appear to be
comparable to Cochrane review 2005. The Cochrane
Out of the total 45 study subjects 28 (Males – 20, Females review, had participants with uncompromised manual
– 8) were of 12-15 year and 17 (Males – 12, females – 5) dexterity.
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Comparison of powered toothbrush in mentally challenged children
and gingivitis which may be clinically significant. Furthur
studies including a wider range of IQ levels with a longer
duration and a crossover design may shed more light on
our understanding of the use of powered toothbrushes with
or without parental assistance. Such studies can be of help
in improving the oral health and quality of life of this
important subsection of the population.
The group with “Powered Tooth Brush alone” was
significantly more effective in reducing gingival scores
than manual brushing alone. Contrasting results were
obtained by Penick et al (2004)25 and Clinical Research
Associates (1998)126. A parallel study design was used for
this study in contrast to another study2 which used a
crossover study design. However, powered tooth brush
‘with parental assistance’ did not reach statistically
significant level. It should also be noted that the difference
between powered with OR without parental assistance was
also not significant. Future research could be carried out
with higher sample size with longer duration to elucidate
the difference.
The compliance in use of powered toothbrushes was
99% which was seen to be higher than in another study6.
The Motion toothbrush is available in bright colourful
shades, has a newly designed soft round handle to give
better control in wet conditions and to enable easier use
for children with poor manual coordination. These features
may all have contributed to the good compliance. Parental
involvement, in terms of assisting and encouraging their
children to maintain good oral hygiene practices, may also
have increased compliance.
The study duration used for the study was of 4 weeks
which was similar to other studies 14,15,18 and was more than
the study conducted by Nourallah et al19. Other studies
have been reported in a review by Walmsley A27 to have
less than 20 participants in each group. In the present study
duration of 30 days and the sample size of 15 in each group
was fixed in accordance to the ADA acceptance program
clinical study guidelines for toothbrushes11. Increasing the
study duration can be a method of minimizing the novelty
effect by testing the brushes over a relatively long period
of time in order to allow the novelty effect to subside or
disappear28. As no significant differences were found
between the mean scores of the 3 groups at baseline, they
were considered homogenous at baseline hence no oral
prophylaxis was performed which is in contrast to another
study2.
Most of the parents favoured the powered tooth brush
as it was easy to maneuver in the oral cavity and thus
resulted in cleaner teeth subjectively, which was confirmed
objectively by reduction of plaque and gingival scores.
All the study subjects belonged to the mild mentally
challenged group. It was observed that they were able to
use the powered toothbrush on their own without any great
difficulty.
Thus use of powered toothbrush in mild mentally
challenged children may be a good idea in reducing plaque
JPDA Vol. 22 No. 01 Jan-Mar 2013
CONCLUSION
Within the limitations of the short term study on this
type of tooth brush and this type of population, powered
toothbrush with parental assistance in comparison to manual
toothbrush achieved significant reduction in plaque levels
& powered toothbrush alone reduced gingivitis levels
significantly.
ACKNOWLEDGEMENTS
1. Principal - Kamayani School for Mentally Challenged,
Pune.
2. Colgate Palmolive (I) Ltd.
DISCLAIMER
The authors do not have any commercial interest in
any of the products used in the study.
REFERENCES
1. Tandon S, Sudha P. Dental care of disabled children –
A Pilot study. J Indian Soc Pedo Prev Dent 1986: 2531.
2. Cem Dogan M, Alacam A, Asici N, Odabas M,
Seydaoglu G. Clinical evaluation of the plaque
removing ability of three different toothbrushes in a
mentally disabled group. Acta Odontol Scand 2004;
62: 350-354.
3. Holcomb FH, Taylor PP, Saunders WA. Comparison
of two oral hygiene devices for the physically
handicapped. J Dent Child 1970. 53-58.
4. Owen TL. A clinical evaluation of electric and manual
toothbrushing by children with primary dentitions. J
Dent Child 1972. 15-21.
5. Bratel J, Berggren U, Dr. Odont. Long term oral effects
of manual or electric toothbrushes used by mentally
handicapped adults. Cli Prev Dent 1991; 13:5-7.
6. Stalnacke K, Soderfeldt B, Sjodin B. Compliance in
use of electric toothbrushes. Acta Odontol Scand 1995;
45
Jamkhande A/ Hedge-Shetiya S/ Shirahatti R
Comparison of powered toothbrush in mentally challenged children
18.Garcia-Godoy F, Marchushamer M, Cugini M, Warren
PR. The safety and efficacy of a children’s power
toothbrush and a manual toothbrush in 6-11 year-olds.
Am J Dent 2001; 14:195-199.
19. Nourallah AW, Spleith CH. Efficacy of occlusal plaque
removal in erupting molars: A comparison of an electric
toothbrush and the cross brushing technique. Caries
Res 2004; 38: 91-94.
20.Verma S, Mahalinga Bhat K. Acceptability of powered
toothbrushes for elderly individuals. J Public Health
Dent 2004; 64:115-117.
21.Biesbrock AR, Bartizel RD. Plaque removal efficacy
of a prototype power toothbrush compared to a control
manual toothbrush. Am J Dent 2005; 18: 116-120.
22.Zimmer S, Strauss J, Bizhang M, Krage T, Raab WHM, Barthel C. Efficacy of the Cybersonic in comparison
with the Braun 3D Excel and a manual toothbrush. J
Clin Periodontol 2005; 32: 360-363.
23.Ciancio S. Electric toothbrushes- For whom are they
designed? Adv Dent Res 2002; 16: 6-8.
24.Robinson PG, Deacon SA, Deery C, Heanue M,
WalmsleyAD, Worthington HV, Glenny AM, Shaw
WC.Manual versus powered toothbrushing for oral
health. Cochrane Database Syst Rev. 2005 Apr
18;(2):CD002281
25.Penick C. Power toothbrushes: A critical review. Int J
Dent Hygiene 2004; 4: 40-44.
26.Aass AM, Gjermo P. Comparison of oral hygiene
efficacy of one manual and two electric toothbrushes.
Acta Odontol Scand 2000; 58: 166-170.
27.Walmsley AD. The electric toothbrush: A review. Br
Dent J 1997; 182: 209-218.
28.Heasman PA, McCracken GI. Clinical evidence for the
efficacy and safety of powered toothbrushes. Adv Dent
Res 2002; 16: 9-15.
53: 17-19.
7. Tritten CB, Armitage GC. Comparison of a sonic and
a manual toothbrush for efficacy in supragingival plaque
removal and reduction of gingivitis. J Clin Periodontol
1996; 23: 641-648.
8. Bullen C, Rubenstein L, Saravia ME, Mourino AP.
Improving children’s oral hygiene through parental
involvement.J Dent Child 1988. 125-128.
9. Mental retardation at; http://en.wikipedia.org/wiki/
Mentalretardation. Accessed; 18th August 2008.
10. Dunning JM. Principles of Dental Public Health. 4th
ed. Harvard University Press; 1984: 322.
11.Yankel SL. Toothbrushing and toothbrushing techniques,
in Primary Preventive Dentistry by Harris NO, Christen
AG, 4th ed. 1994: 79-104.
12.Loe H, Silness J. Periodontal disease in pregnancy:
1.Prevalence and severity. Acta Odontol Scand 1963;
21:533-551.
13.Turesky S, Gilmore ND, Glickman I. Reduced plaque
formation by the chloromethyl analogue of Victamine
C. J Periodontol 1970; 41: 41-43.
14.Bratel J, Berggren U, Dr. Odont and Hirsch JM, Dr.
Odont. Electric or manual toothbrush? A comparison
of the effects on the oral health of mentally handicapped
adults. Clin Prev Dent 1988; 10:23-26.
15.Baab DA, Johnson RH. The effect of a new electric
toothbrush on supragingival plaque and gingivitis. J
Periodontol 1989; 60: 336-341.
16.Stolze K, Bay L. Comparison of a manual and a new
electric toothbrush for controlling plaque and gingivitis.
J Clin Periodontol.1994; 21: 86-90.
17.Jongenelis APJM, Wiedemann W. A comparison of
plaque removal effectiveness of an electric versus a
manual toothbrush in children. J Dent Child 1997; 176182.
46
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