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139JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2012 | Issue 2 | Vol 30 |

Original article

The effectiveness of a musical toothbrush for dental plaque removal: A comparative study

Ganesh M, Shah S, Parikh D, Choudhary P, Bhaskar VDepartment of Pedodontics and Preventive Dentistry, Ahmedabad Dental College and Hospital, Gandhinagar, Gujarat, India

Correspondence: Dr. M. Ganesh, Reader, Department of Pedodontics and Preventive Dentistry, Ahmedabad Dental College and Hospital, Gandhinagar, Ahmedabad, India. E-mail: [email protected]

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DOI: 10.4103/0970-4388.99988

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Abstract

Background and Objectives: the purpose of this study was to clinically evaluate and compare the efficacy of “Brush Buddies” musical tooth brush and Colgate Smile tooth brush in the reduction of established plaque and gingivitis. Materials and Methods: for this study, 120 healthy kids (73 boys and 47 Girls) were selected. The subjects were randomly assigned into two groups by a second examiner; one group used Colgate Smile brush and the other group used “Brush Buddies” musical tooth brush. Plaque index (Quigley and Hein), Modified Gingival Index (Lobene and Associates) and Gingival Bleeding Index (Ainamo and Bay) were assessed at baseline, 30th day, 60th day, and 90th day. Results: all the baseline indices appeared to be well balanced. At the end of the study, reduction in plaque index, modified gingival index and gingival bleeding index were statistically highly significant during each interval for both the toothbrushes. For “Brush Buddies” musical tooth brush, the reduction in all clinical parameters were statistically significant for 30 days and 60 days interval, while nonsignificant at 90 days interval. Interpretation and Conclusion: both the tooth brushes used in this study were clinically effective in removing plaque, improving gingival health. Musical tooth brush is more effective initially but as the time period increases both tooth brushes give almost similar results.

Key words

Established plaque, fone’s technique, gingivitis, musical tooth brush

Introduction

Prevention has become the corner stone of the modern dental practice and effective plaque control is the basic password to the meaningful practice of preventive dentistry. Intraoral cleaning devices have been a part of human civilization since long and a strong correlation exists between the severity of gingivitis and periodontitis and the accumulation of dental plaque.[1]

Dentistry has evolved a lot from the simple tooth pick to today’s state-of-the-art technology. The modern toothbrush was invented by Chinese during the Tang Dynasty.[2] Since then the tooth brush has undergone a lot of change in every aspect except that the purpose of its action has remained the same – to attain a plaque free tooth surface, thereby preventing the initiation and progression of gingival and periodontal disease. Various chemical and other mechanical methods have been advocated for this purpose, but tooth brushing has been cited as the most commonly used effective and safest therapeutic method to remove plaque.[3]

It has been shown that tooth brushing practiced by the majority of the population is unsatisfactory. De La Rosa suggested that an average child removes only about 50% of the plaque present on teeth.[4] Poor oral hygiene and periodontal disease are still prevalent in children from rural area (low socioeconomic status). As a result, dental caries, periodontal disease, and tooth loss remain an epidemic health problems are common

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Ganesh, et al.: The effectiveness of a musical toothbrush for dental plaque removal

140 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2012 | Issue 2 | Vol 30 |

in children. The normal oral flora (flora associated with oral health) can be greatly altered as a result of poor oral hygiene, leading to higher levels and a more pathogenic type of oral flora. A basic approach to addressing these problems has been to seek easier and more effective tooth brushing methods.[5]

Bratel and Berggren compared a manual toothbrush with an electric toothbrush and concluded that the electric toothbrush was not superior to the manual brush.[6] Similar findings were made by others when comparing manual brushes with electric brushes.[7,8] Studies have also compared foam brushes, Collis-curve brushes, deep-ground brushes, and double-headed brushes with standard manual brushes with no or small site-specific differences in the ability of these devices to remove plaque mechanically.[9]

In the case of children, majority show noncompliance toward brushing and they try to hide themselves from daily brushing task because they it considered as tedious procedure and dislike the brushing. At the same time parents try to motivate the children for regularly brushing by using different methods such as contingency management, gifts, and even pleasing them with bribe at times. Still most of the parents fail to develop the child’s interest in brushing. It is important to gain child’s interest in brushing by introducing some new devices that child can enjoy the brushing. Recently musical talking tooth brush “Brush Buddies,” which is used widely in USA, is introduced in Indian market by Ashtel Dental, USA [Figure 1]. In this brush, music starts while child starts brushing, it continuous during the brushing and when this ends child should end the brushing. Till date no reported studies have been done to compare between musical and normal tooth brush. Keeping this thing in mind, we have formulated a study as described in the following.

Aims and objectivesThe present clinical study was undertaken with the aim to clinically evaluate and compare the efficacy of musical tooth brush using Fone’s technique as compared to normal toothbrush with Fone’s technique in the reduction of established plaque, gingivitis.

Materials and Methods

After obtaining ethical approval from Ethical Committee of Ahmedabad Dental College a total of 475 kids were screened from the four different government schools in Kalol Taluka, Gandhinagar. Out of that 329 kids were selected who fulfilled the inclusion criteria. Informed consent forms were given to all the parents/legal guardian of selected kids. Finally, 120 students’ legal guardian (most cases either parents) gave the consent for participation in the study. The study was conducted in Department of Pedodontics and Preventive Dentistry, Ahmedabad Dental College and Hospital, Gandhinagar. Study includes 120 kids (73 boys and 47 girls) with the age group of 3 to 6 years.

Inclusion criteriaSubjects with good general and oral health.Subjects with moderate gingivitis (according to Loe and Silness) and fair plaque index.Ability of the subjects to attend the hospital at recall intervals.Subjects with full complement of primary teeth present.

Exclusion criteriaSubjects with poor manual dexterity.Subjects taking drugs that could affect the state of the gingival tissues including drugs for convulsion, immunosuppressant, corticosteroids and nonsteroidal anti-inflammatory drugs.Subjects with muco-gingival problems.Subjects with three or more carious teeth that require immediate treatment.Subjects using any other supplemental plaque control devices such as interdental cleansing aids or mouthwashes.Subjects with the habit of chewing tobacco.

Study designA full mouth, single–blind examiner study was conducted. The study was carried out for a period of 90 days. All the clinical parameters were recorded at baseline (0 day), 30th day, 60th day, and 90th day.Figure 1: “BRUSH BUDDIES” musical toothbrush





Experimental procedureThe selected 120 kids children randomly divided in two groups. First group will brush with normal tooth brush [Figures 2 and 3] and second group will brush with musical tooth brush. [Figure 4] Children were assigned the toothbrushes by a second examiner. Only the second examiner knew which child had been given which brush, and was not involved in the recording of clinical parameters. And all clinical parameters were recorded by the first examiner. Instructions and pamphlets regarding the method of brushing technique, handling and manipulation of both the brushes (Colgate Smile and Brush Buddies musical brush) were given with a commercially available fluoridated dentifrice (Cheerio gel) for use throughout the study. The children were asked to refrain from all oral hygiene procedures for 24 h prior to every recall visit.

Clinical parameters recordedModified gingival index[10]

Scoring criteria• Absenceof inflammation.• Mild inflammation: slight change in color, little

change in texture of any portion of the marginal, or papillary gingival unit.

• Mildinflammation:criteriaasabovebutinvolvingentire marginal or papillary gingival unit.

• Moderate inflammation: glazing, redness, edema,and/or hypertrophy of the marginal or papillary gingival unit.

• Severe inflammation: marked redness, edemaand/or hypertrophy of the marginal or papillary gingival unit, spontaneous bleeding congestion, or ulceration.

Totaling around each tooth yields the M.G.I. score for the area. If the scores around each tooth are totaled and divided by four, M.G.I. score for the tooth is obtained. Totaling all the scores per tooth and dividing by the number of teeth examined provides the M.G.I. score per person.

Plaque index[11]

Plaque index: scoring criteria• Noplaque.• Separateflecksof plaqueatthecervicalmarginof

the tooth.• Athin,continuousbandof plaque(upto1mm)at

the cervical margin.• Abandof plaquewiderthan1mmbutcoveringless

than one third of the crown.

• Plaquecoveringatleastonethirdbutlessthantwothirds of the crown.

• Plaquecoveringtwothirdsormoreof thecrown.

Plaque was assessed on the facial and lingual surfaces of all teeth. Totaling all of the plaque scores and dividing by the number of surfaces examined, gives a plaque score per person.

Gingival bleeding index[12]

The presence or the absence of the gingival bleeding is determined by gentle probing of the gingival crevice with a periodontal probe.

Scoring criteria• Presenceof bleeding10safterprobing.• Absenceof bleeding10safterprobing.

The gingival bleeding index is expressed as the percentage of all sites examined that bleed on probing.

Brushing techniqueThe parents were instructed to observe their child while he/she is performing brushing.1. Wet the head of the tooth brush before using.2. Place the assigned tooth paste on the brush head.3. The child is asked to stretch his/her arm such that

they are parallel to the floor.4. Then asked to make big circles using whole arm to

draw circles in the air.5. The circles are reduced in diameter until very small

circle are make in front of mouth.6. Now the child is asked to press the brush bristles on

all surfaces of teeth and then make same circles on teeth.

7. Spend at least 3 min to brush all surfaces of the teeth.

8. After use, drain off the moisture well and keep the tooth brush in an airy place.

Instructions1. Use only the given brushes following the specified

technique.2. Brush twice daily each time for 3 min with the

assigned dentifrice only.3. Refrain from brushing 24 h before every recall visit.4. Return for periodic examination after every 30 days

till the end of the study.5. Do not use any medication or mouthwash that could

have an inhibitory effect on plaque.





Results

The study was conducted in a single blind manner with the chief investigator being unaware of which subject was using which toothbrush. There were no dropout cases and all the subjects maintained their recall appointments. Paired t test was used to check intra group variables while unpaired t test was used to check intergroup variables. The results were interpreted as follows. Colgate smile brush [Figure 2]. Modified gingival index [Table 1].

The mean Modified Gingival Index (M.G.I) score at baseline was 1.67 ± 0.23 that was reduced at all time intervals i.e. at 30, 60, and 90 days, the value of P < 0.001, this was statistically highly significant. Plaque index [Table 2].

The mean Plaque index (P.I) score at baseline was 1.70 ± 0.18 which was reduced at all time intervals, that is, at 30, 60, and 90 days, the value of P < 0.001, this was statistically highly significant. Gingival bleeding index (Mean scores in Percentage) [Table 3].

The mean Gingival Bleeding Index (G.B.I) score at baseline was 43.0 ± 4.2 that was reduced at all time intervals, that is, at 30, 60, and 90 days, the value of P < 0.001, this was statistically highly significant. Musical brush (Brush Buddies) modified gingival index [Table 1].

The mean modified gingival index (MGI) score at baseline was 1.68 ± 0.18, which was reduced at all time intervals, that is, at 30, 60, and 90 days, the value of P < 0.001, this was statistically highly significant. Plaque index [Table 2].

The mean plaque index (PI) score at baseline was 1.78 ± 0.21, which was reduced at all time intervals that is at 30, 60, and 90 days, the value of P < 0.001, this was statistically highly significant. Gingival bleeding index (mean scores in percentage) [Table 3].

The mean gingival bleeding index (GBI) score at baseline was 41.9 ± 7.0, which was reduced at all time intervals, that is, at 30, 60, and 90 days, the value of P < 0.001, this was statistically highly significant.

Comparison of reduction in modified Gingival Index between musical tooth brush and Colgate smile brushThe mean reduction in the MGI score on intergroup comparison, the difference at 30 days (P = 0.04), at

Figure 2: Colgate smiles toothbrush

Figure 3: Child brushing with Colgate Smile

60 days (P = 0.04) were statistically significant while at 90 days (P = 0.17) it was found to be statistically nonsignificant [Table 4].

Figure 4: Child brushing with Brush Buddies





Comparison of reduction in Plaque Index between musical tooth brush and Colgate smile brushThe mean reduction in the PI score on inter-group comparison, the difference at 30 days (P = 0.032), at 60 days (P = 0.042) were statistically significant and at 90 days (P = 0.10) it was found to be statistically nonsignificant [Table 5].

Comparison of reduction in Gingival Bleeding Index between musical tooth brush and Colgate smile brushThe mean reduction in the GBI score on intergroup comparison, the difference at 30 days (P = 0.039), at 60 days (P = 0.042) were statistically significant and at 90 days (P = 0.93) it was found to be statistically nonsignificant [Table 6].

Discussion

As periodontal investigation began to discover the aetiological effect of dental plaque and the therapeutic role of oral hygiene became clear,[1,13,14]

various mechanical devices and chemical agents were introduced for plaque control. Although these have been proved to be effective to some extent, but mechanical plaque removal using tooth brush still remains the most popular and effective method.

In the case of children, the major problem is to have their compliance in brushing the teeth twice a day. Mostly children use to refrain from brushing because they consider as a tedious procedure. At 3–5 years of age most of child cannot understand the importance of brushing. So the brushing should be introduced in such a way that child can enjoy it rather than to ran away from it. As an effective option the musical tooth brush can solve this problem. This tooth brush consists of the handle that is available in different animal shape and also when we press the button the music will play for 3 min. When music starts, the child will start the brushing when the music stop the child will stop the brushing. Thus, child will enjoy and brush teeth regularly for 3 min twice a day. The basic aim of this study is to check compliance from the child while using this type of brush.

Table 1: Reduction in modified gingival index from baselineTime of assessment (days)

Colgate smile Brush Buddies musical toothbrushMean ± SD Reduction from

baselineReduction % t* P Mean ± SD Reduction from

baselineReduction

%t* P

0 (Baseline) 1.67 ± 0.23 — — — — 1.68 ± 0.18 — — — —30 1.40 ± 0.08 0.27 ± 0.20 16.2 6.19 <0.001 1.26 ± 0.08 0.42 ± 0.18 26.0 8.12 <0.00160 1.23 ± 0.07 0.44 ± 0.21 26.3 9.59 <0.001 1.10 ± 0.04 0.58 ± 0.17 29.6 12.53 <0.00190 1.17 ± 0.06 0.50 ± 0.20 29.9 11.26 <0.001 1.16 ± 0.05 0.51 ± 0.19 30.4 12.12 <0.001

Table 2: Reduction in the plaque index from baselineTime of assessment (days)

Colgate smile Brush Buddies musical toothbrushMean ± SD Reduction

from baselineReduction

%t* P Mean ± SD Reduction

from baselineReduction

%t* P

0 (Baseline) 1.70 ± 0.18 — — — — 1.78 ± 0.21 — — — —30 1.41 ± 0.09 0.29 ± 0.17 17.1 7.52 <0.001 1.29 ± 0.09 0.49 ± 0.19 25.9 8.88 <0.00160 1.31 ± 0.17 0.39 ± 0.28 22.9 6.25 <0.001 1.17 ± 0.08 0.61 ± 0.19 31.2 11.90 <0.00190 1.20 ± 0.05 0.50 ± 0.19 29.4 12.06 <0.001 1.19 ± 0.04 0.61 ± 0.21 34.3 13.02 <0.001

Table 3: Reduction in the gingival bleeding index from baselineTime of assessment (days)

Colgate Smile Brush Buddies Musical toothbrush

Mean ± SD Reduction from

baseline

Reduction %

t* P Mean ± SD Reduction from baseline

Reduction %

t* P

0 (Baseline) 43.0 ± 4.2 — — — — 41.9 ± 7.0 — — — —30 34.1 ± 6.3 8.9 ± 3.7 20.7 10.80 <0.001 33.4 ± 4.2 12.5 ± 4.0 27.1 11.9 <0.00160 30.6 ± 3.7 12.4 ± 2.5 28.8 22.21 <0.001 32.9 ± 3.8 15.0 ± 4.6 33.0 12.70 <0.00190 27.6 ± 3.6 15.4 ± 2.7 35.8 25.82 <0.001 26.4 ± 3.5 15.5 ± 4.6 37.0 15.1 <0.001





To reduce the examiner bias, the study was designed as a single blind. The examiner who scored the indices was unaware of which student was using which particular brush. The second examiner, who had selected the children according to inclusion/exclusion criteria, was only knowing which tooth brush had been allotted to which particular child. The second examiner was not involved in the recording of clinical parameters at any of the recall visits.

This study design was in accordance with the ADA guidelines[15] for the clinical tooth brush trials, that for each product 120 subjects were enrolled in the study. In the present study, subjects were asked to refrain from oral hygiene measures for 24 h before each recall visits which is in accordance with Van der Weijden et al.[16] The overnight plaque test model is highly reproducible[17] and allows a reasonable result in a short period of time and also using a lower prebrushing plaque score can affect the final outcome of the study. This also reduced the “Hawthorne effect.”[18]

From this study, it is evident that regardless the type of brush, regular oral hygiene maintenance can reduce the plaque deposition and improve the gingival health. But the comparison between two groups does not show statistically significant difference between them. So both toothbrushes can be effective if they are used at regular basis with proper technique.

The better results were shown by the musical tooth brush group during 30 and 60 days follow up. It can be explained

by the sound while brushing the teeth. The fact that music makes the child motivated to brush his/her teeth and better participation in the brushing. The child feels like playing with a toy while brushing the teeth. This allows the child to brush more regularly and properly. But later on as the time progresses the child become habitual with brushing and regardless of the type of tooth brush he/she will continue to brush regularly. So at the end of 90 day we found no significant difference in oral hygiene index.

Designing a short-term clinical study to test the efficacy of plaque removal is not an easy task. Many different factors such as frequency, duration, technique, thoroughness of tooth brushing, manual dexterity, motivation, individual pathogenicity of plaque formation, type of dentifrice used, regularity of subjects, and novelty effect may interfere with results.[2,19] This study design was developed in order to minimize the effects of these variables as much as possible.

Based on the present data, the musical tooth brush may be assigned as the better tooth brush as compared to the Colgate smile tooth brush, but the difference between the two is statistically insignificant. Thus, the results of this study demonstrate that both the toothbrushes have a great potential to remove plaque, improve gingival health and reduce halitosis effectively.

Conclusion

Following conclusions can be drawn from the study

Table 4: Comparison of reduction (changes) in modified gingival index between the two brushesTime interval (days) Colgate smile Brush Buddies musical toothbrush Significance of difference

Mean reduction ± SD Reduction % Mean reduction ± SD Reduction % Mean difference t* P0-30 0.27 ± 0.20 16.2 0.42 ± 0.18 26.0 0.8 0.74 0.046 0-60 0.44 ±0.21 26.3 0.58 ± 0.17 29.6 0.7 0.54 0.049 0-90 0.50 ± 0.20 29.9 0.51 ± 0.19 30.4 0.1 0.16 0.17

Table 5: Comparison of reduction (changes) in plaque index between the two brushesTime interval (days) Colgate smile Brush Buddies musical toothbrush Significance of difference

Mean reduction ± SD Reduction % Mean reduction ± SD Reduction % Mean difference t* P0-30 0.29 ± 0.17 17.1 0.49 ± 0.19 25.9 2.0 1.61 0.032 0-60 0.39 ± 0.28 22.9 0.61 ± 0.19 31.2 2.1 1.60 0.0420-90 0.50 ± 0.19 29.4 0.61 ± 0.21 34.3 1.1 1.68 0.10

Table 6: Comparison of reduction (changes) in gingival bleeding index between the two brushesTime interval (Days) Colgate smile Brush Buddies musical toothbrush Significance of difference

Mean reduction ± SD Reduction % Mean reduction ± SD Reduction % Mean difference t* P0-30 8.9 ± 3.7 20.7 12.5 ± 4.0 27.1 3.6 1.35 0.0390-60 12.4 ± 2.5 28.8 15.0 ± 4.6 33.0 2.6 0.51 0.0420-90 15.4 ± 2.7 35.8 15.5 ± 4.6 37.0 0.1 0.09 0.93





• ThereductioninPlaqueIndex,ModifiedGingivalIndex and Gingival Bleeding Index was highly significant during each interval, for both the tooth brushes.

• Thedifferencesinthereductionof clinicalparametersbetween the two brushes were statistically significant during the 30 days and 60 days follow up while non significant at 90 days follow up.

• Overall,Musicaltoothbrushwasshowntobemoreeffective than the Colgate Smile toothbrush on the percentage basis.

• Boththebrushesaresafeandeffectiveforchildrenwhen used supervised on regular basis for the removal of human dental plaque.

References

1. Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontal 1965;36:177-87.

2. Norman HO. Toothbrushes and tooth brushing methods. In: Primary Preventive Dentistry, 6th Ed. Pearson Education Ltd, London 2004. Available from: http://www.albadr.org/www/pdf/library/654,PDF. [Last accessed on 2012 Jun 04] .

3. Sicilia A, Arregui I, Gallego M, Cabezas B, Cuesta S. A systematic review of powered vs. manual toothbrushes in periodontal cause-related therapy. J Clin Periodontol 2002;29 (Suppl. 3):39-54.

4. De la Rosa M, Zacarias Guerra J, Johnston DA, Radike AW. Plaque growth and removal with daily tooth brushing. J Periodontal 1979;50:661-4.

5. Loesch W. Ecology of the oral flora. In: Newman G, Nisengard RJ, Oral microbiology and immunology. Philadelphia: W.B. Saunders; 1998. p. 351-66.

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14. Axelson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. J Clin Periodontal 1978;5:131-51.

15. Council on Scientific Affairs of ADA. American Dental Association Acceptance Program Guidelines for Toothbrushes, 2009. Available from: http://www.ada.org/sections/science and research/pdfs/guide_toothbrushes.pdf. [Last accessed on 2012 Jun 04]

16. Van der Weijden GA, Timmerman MF, Reijerse E, Mantel MS, Van der Velden U. The effectiveness of an electronic toothbrush in the removal of established plaque and treatment of gingivitis. J Clin Periodontol 1995;22:179-82.

17. Yankell SL, Emling RC, Shi X. Interproximal access efficacy of sonicare plus and braun oral-B Ultra compared to a manual toothbrush. J Clin Dent 1997;8:26-9.

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How to cite this article: Ganesh M, Shah S, Parikh D, Choudhary P, Bhaskar V. The effectiveness of a musical toothbrush for dental plaque removal: A comparative study. J Indian Soc Pedod Prev Dent 2012;30:139-45.

Source of Support: Nil, Conflict of Interest: None declared.



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