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Table of Contents   
ORIGINAL RESEARCH  
Year : 2019  |  Volume : 30  |  Issue : 2  |  Page : 196-199
Effectiveness of musical toothbrush on oral debris and gingival bleeding among 6–10-year-old children: A randomized controlled trial


Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India

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Date of Web Publication29-May-2019
 

   Abstract 

Context: Motivation serves to be an integral part of health promotion to children at the learning phase of their life. Aim: Evaluation of the effectiveness of musical toothbrush over regular toothbrush in the debris and gingival bleeding scores among children. Settings and Design: This was a single-blinded parallel, randomized controlled trial conducted among 6–10-year-old schoolchildren in Chennai. Methods: One hundred participants with allocation ratio of 1:1 were assigned to musical and regular toothbrush group by simple randomization. After baseline evaluation (T0) of Debris Index-Simplified (DI-S) and Gingival Bleeding Index (GBI), outcome variables were assessed for a period of 3 months (T1, T2, and T3). Statistical Analysis Used: Friedman test and Mann–Whitney statistical test were used to compare the outcome variables within and across the two groups. Results: Thirty-two boys and 68 girls (mean age: 8.53 years) participated in the study. Statistically significant difference was seen in DI-S score among musical toothbrush group (mean: 0.50 [T3] and GBI score: 8.18% [T3]) when compared to regular toothbrush group (mean: 1.59 [T3] and GBI score: 23.54 [T3]) at the end of the 3rd month. Conclusion: Although both the musical and regular toothbrushes effectively reduced the DI-S and GBI scores, former showed effective change among children when compared to the latter.

Keywords: Behavior, children, motivation, oral health, toothbrush

How to cite this article:
Subburaman N, Madan Kumar PD, Iyer K. Effectiveness of musical toothbrush on oral debris and gingival bleeding among 6–10-year-old children: A randomized controlled trial. Indian J Dent Res 2019;30:196-9

How to cite this URL:
Subburaman N, Madan Kumar PD, Iyer K. Effectiveness of musical toothbrush on oral debris and gingival bleeding among 6–10-year-old children: A randomized controlled trial. Indian J Dent Res [serial online] 2019 [cited 2019 Dec 7];30:196-9. Available from: http://www.ijdr.in/text.asp?2019/30/2/196/259212

   Introduction Top


Children are very important part of a country's demography and their health influences the future of the nation. School-going age is regarded as the influencing stage in a child's life where lifelong sustainable oral health-related behavior, belief, and attitude can be established with long-lasting impact.[1] Recommendations for at-home preventive measures, including brushing infants and young children's teeth and using fluoridated toothpaste, are the key elements of anticipatory guidance which are to be provided to parents by the child's dental home.[2] Perhaps, only a relatively few parents meet professional's recommendations to brush their children's teeth twice a day.

A child's intention to perform a behavior can be impeded by external constraints or the individual's lack of skill. A strong intention, the necessary skills, and lack of constraints are the sufficient conditions required for behavioral performances among them.[3] A poor oral hygiene occurring due to increasing plaque and calculus deposits with increasing age has been reported among children and adolescents.[4],[5],[6] This could be attributed to the fact that there is a lack of motivation among them to follow the practice of brushing as a regular habit. Although many chemical methods have come up, toothbrushing serves to be the gold standard in reducing dental plaque. However, effective toothbrushing depends on a technically correct toothbrushing technique and patient compliance. De Las Rosa suggested that an average child removes only 50% of all plaques present on the teeth. The children's capacity to use toothbrush varies greatly not only according to their age but also their individual dexterity and motivation.[7]

Literature search has revealed that three factors contribute for effective toothbrushing among children, namely, the duration, frequency, and the technique of toothbrushing.[8],[9],[10] However, the combined effect of these three major factors along with other factors such as thoroughness of toothbrushing, manual dexterity, and motivation shall play a cumulative role in effective plaque removal. Besides these, parents consider that the difficulty of brushing their children's teeth was due to the changing day-to-day routine and the subsequent difficulty in forming a toothbrushing habit among them. Motivating factors for brushing children's teeth were largely short term.[11]

A study by Huebner and Riedy suggested that parents who brushed their child's teeth two times a day or more were more likely to describe utilizing specific skills (making it fun) to overcome the barriers to brushing.[12] In order to make toothbrushing habit more interesting to children and to gain their attention, toothbrush with music and light system (Brush Buddies Brite Beatz Toothbrush®) has been introduced in the United States. With this brush, the light and the music play when the child starts brushing and continues up to 2 min until music and light stop. This method is proposed to inculcate a habit of 2-min toothbrushing habit among them. The benefits of music among children include a sense of positive mood, attention, and learning practices in the children.[13] Moreover, the effect of light provides a visual environment that motivates them and alters their mental attitude and performance skills.[14] Thus, the combined effect of the two gives them a sense of happiness, fantasy, arousal, and energy to perform any work.

A study conducted by Ganesh et al.[15] compared the effectiveness of the musical and normal toothbrushes and suggested that both the toothbrushes were found to be safe and effective for children. However, there are only few studies that have been reported to compare the efficiency of regular toothbrush and the musical toothbrush in effective plaque removal. Hence, the aim of the study was to evaluate the effectiveness of musical toothbrush in the assessment of the debris and gingival bleeding scores among 6–10-year-old children. The objective of the study was to compare the change in the debris and gingival bleeding scores among the musical toothbrush over the regular toothbrush group.


   Methods Top


An investigator-blinded, parallel-group, randomized controlled trial was conducted for a period of 3 months (September–December 2016), to assess the change in the Debris Index-Simplified (DI-S) and Gingival Bleeding Index (GBI) scores of children aged 6 to 10 years. The study was undertaken with the understanding and written consent from the parents of each participant. The study design was approved by the Ethics Committee of Ragas Dental College and Hospital. Permission was obtained from school authorities before the initiating the study. The clinical trial was registered in the clinical trial registry, India (CTRI/2017/07/009151). This randomized controlled trial was reported in accordance with the Consolidated Standards of Reporting Trials statement.[16]

The trial was conducted under school setting. Initially, five different schools adopted by the college, in and around Chennai, were identified. Among them, only one of the schools consented and permitted to enroll the children for the study. Five hundred participants from Grade I to Grade V were chosen using convenience sampling. Among them, 300 participants provided consent to participate in the study. The eligibility criteria for the recruitment were participants with a DI-S score as per the Oral Hygiene Index-Simplified (OHI-S, given by Greene and Vermillion)[17] of more than one. The exclusion criteria were as follows:

  • Participants with poor manual dexterity
  • Differently abled children who require special assistance for brushing
  • Those participants who had visited dentist for a dental treatment past 1 month and thereafter
  • Participants who had undergone orthodontic treatment
  • Those participants with any systemic and acute illness and under medication.


On the basis of eligibility criteria, 100 participants (68 girls and 32 boys) who fulfilled the aforementioned criteria were randomly grouped using simple randomization method by generating a table of random numbers. Randomization was carried out by a blinded research collaborator who was unaware of the study groups and design. An allocation ratio of 1:1 with 50 participants each in intervention and control group, respectively, was enrolled in the study [Figure 1]. A research collaborator, who was not going to participate in subsequent stages of study, was assigned to allocate toothbrush to the participants in both the groups, respectively.
Figure 1: Flowchart of the phases of the two study groups in the trial (n, number of participants)

Click here to view


Group 1 (music and light toothbrush – Brush Buddies Brite Beatz Toothbrush®): Instructions were given to stop brushing once the music and light in the brush stop after 2 min. Adequate training and reinforcement were done to the study participants on using the toothbrush.

Group 2 (regular toothbrush – Colgate Smiles Junior Soft Toothbrush®): Training was given to the study participants on the proper toothbrushing technique using the regular toothbrush.

Before providing the intervention, all the students participating in the study and their parents underwent training over a half-day session, using demonstration models and audiovisual aids covering

  1. The importance of brushing in the prevention of various oral diseases in children
  2. The proper toothbrushing technique (horizontal scrub technique)[10]
  3. The American Dental Association (ADA) recommended 2 min × 2 times thorough brushing.[8],[9]


At the end of the training session, clarification of doubts by the children and their parents and proper reinforcement of the procedure was ensured.

Clinical dental examination and outcome variables

A single-blinded calibrated examiner judged the patients eligible for the study. ADA classification Type III intraoral examination was carried out among the study participants. DI-S of OHI-S given by Greene and Vermillion and GBI by Ainamo and Bay (1975) were recorded on a data sheet, considering it to be the baseline values (T0).

After evaluating the baseline values, study participants were examined for a follow-up examination by the same examiner who conducted the baseline examination (T0) and who was blind to group allocation status. Follow-up examinations were carried out once in every 30 days, for a period of 3 months (at time intervals, i.e., T1, T2, and T3). In addition, the participants under Group 1 were asked to refrain from using the musical toothbrush, thereby continuing with the regular toothbrush after the 2-month follow-up.

The data collected were entered in the Microsoft Excel sheet following which statistical analyses were carried out using SPSS (v.22)™ (SPSS Inc., Chicago, IL., USA). The Shapiro–Wilk test for normality revealed a nonnormal distribution for both the outcome variables (DI-S and GBI). The mean age and scores for DI-S and GBI were calculated using descriptive statistics. The Mann–Whitney test was used to compare the outcome variables across the groups. To assess variance in performance between baseline (T0) and 3 months (T1, T2, and T3), Friedman test was carried out. The two-tailed P < 0.05 was considered statistically significant.


   Results Top


The distribution of baseline characteristics of the study participants overall and within the groups suggests that randomization was fair. Thirty-two boys and sixty-eight girls (mean age: 8.53 years) were participated in the study. [Table 1] demonstrates the distribution of mean DI-S and GBI scores in both the groups during the study period.
Table 1: Distribution of mean Debris Index-Simplified and Gingival Bleeding Index scor es among the musical and regular toothbrush groups

Click here to view


The mean DI-S score for musical toothbrush group at baseline (T0) was 2.72, which gradually reduced to 0.50 at T3. The mean DI-S score for the regular toothbrush group at baseline (T0) was 2.64, which gradually reduced to 1.59 at T3.

Furthermore, the percentage of GBI score at the baseline (T0) was 57.68%, which reduced to 8.18% at T3 in the musical toothbrush group and 59.47% (T0), which has reduced to 23.54% at T3 in the regular toothbrush group. A statistically significant difference in the mean scores of DI-S (P < 0.001) and GBI (P < 0.001) was seen between the two groups at T1, T2, and T3 study periods.


   Discussion Top


The present intervention study was conducted to assess the effectiveness of a music- and light-based toothbrush when compared to that of regular toothbrush over 3 months, among 6–10-year-old school-going children. The latter was chosen as the study population since this is the appropriate age where they focus on a variety of activities and develop skills requiring manual dexterity.[17]

The results of the present study demonstrated a statistically significant reduction in DI scores and GBI scores among musical toothbrush group when compared to the regular toothbrush group. Nevertheless, it should be noted that the DI and GBI scores reduced in both the study groups when compared to the baseline values. On a general note, it can be argued that the reduction in the debris and gingival bleeding could be attributed to the health education provided among both the groups. A study by Worthington et al.[18] showed a significantly lower mean plaque scores and greater knowledge about toothbrushes among children who received dental education program compared to their control group. A similar study by Creeth et al.[19] suggested that reinforcement to the children by the oral health-care professionals toward longer period of brushing increased plaque removal significantly.

A study reported that parents identified the lack of time and the uncooperative behavior of their children as the most common barriers toward brushing. In order to encourage the same and to improve their children's cooperation toward brushing, the most common method was to make it “fun.”[12] Children considered the musical toothbrush as an object of fantasy. Exposure to music along with synchronized light show improves the child's motor functioning and thereby enhances their transfer-of-learning task.[20] A study conducted by Ganesh et al.[15] suggested that musical toothbrush was found to be more effective than the regular toothbrush in reduction of plaque scores on the percentage basis. Similar results were obtained in this study, suggesting that the effect of light and music incorporated in the toothbrush may have a positive influence in the toothbrushing behavior among children. However, quantitative assessment of the same was not carried out and thereby forms one of the limitations of the study.

Besides, other factors such as the thoroughness of toothbrushing, parental influence, individual pathogenicity of plaque formation, type of dentifrice used, and regularity of participants need to be considered. Hence, further research has to be carried out in a similar but larger sample along with a crossover design.


   Conclusion Top


The results of the study concluded that effective dental health education along with proper toothbrushing practice served to be a prime factor in the improvement of the debris and gingival bleeding scores among children in the given time period. Although both the musical and the regular toothbrush effectively reduced the DI-S scores and GBI scores to a greater extent, the latter being an outcome of “Hawthorne effect” cannot be overlooked. However, the musical toothbrush group had better reduction in the scores during the study period on comparison.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Kwan SY, Petersen PE, Pine CM, Borutta A. Health-promoting schools: An opportunity for oral health promotion. Bull World Health Organ 2005;83:677-85.  Back to cited text no. 1
    
2.
American Academy of Pediatric Dentistry, Council on Clinical Affairs. Policy on Early Childhood Caries: Classifications, Consequences, and Preventive Strategies [Internet]. 2016. Available from: http://www.aapd.org/media/Policies_Guidelines/P_ECCUniqueChallenges.pdf. [Last accessed on 2017 Jan 02].  Back to cited text no. 2
    
3.
Davies GM, Duxbury JT, Boothman NJ, Davies RM, Blinkhorn AS. A staged intervention dental health promotion programme to reduce early childhood caries. Community Dent Health 2005;22:118-22.  Back to cited text no. 3
    
4.
Mbawalla HS, Masalu JR, Astrøm AN. Socio-demographic and behavioural correlates of oral hygiene status and oral health related quality of life, the limpopo-arusha school health project (LASH): A cross-sectional study. BMC Pediatr 2010;10:87.  Back to cited text no. 4
    
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Saied-Moallemi Z, Virtanen JI, Vehkalahti MM, Tehranchi A, Murtomaa H. School-based intervention to promote preadolescents' gingival health: A community trial. Community Dent Oral Epidemiol 2009;37:518-26.  Back to cited text no. 5
    
6.
World Health Organization. Information Series on School Health: Oral Health Promotion Through Schools. Geneva: World Health Organization; 2003.  Back to cited text no. 6
    
7.
Bastiaan RJ. The cleaning efficiency of different toothbrushes in children. J Clin Periodontol 1986;13:837-40.  Back to cited text no. 7
    
8.
Frandsen A. Mechanical oral hygiene practices: State-of-the science review. In: Loe H, Kleinman DV, editors. Dental Plaque Control Measures and Oral Hygiene Practices. Oxford: IRL Press; 1986. p. 93-116.  Back to cited text no. 8
    
9.
American Academy of Pediatric Dentistry. Guideline on adolescent oral health care. Ref Man 2010;33:129-36.  Back to cited text no. 9
    
10.
Sundell SO, Klein H. Toothbrushing behavior in children: A study of pressure and stroke frequency. Pediatr Dent 1982;4:225-7.  Back to cited text no. 10
    
11.
Trubey RJ, Moore SC, Chestnutt IG. Parents' reasons for brushing or not brushing their child's teeth: A qualitative study. Int J Paediatr Dent 2014;24:104-12.  Back to cited text no. 11
    
12.
Huebner CE, Riedy CA. Behavioral determinants of brushing young children's teeth: Implications for anticipatory guidance. Pediatr Dent 2010;32:48-55.  Back to cited text no. 12
    
13.
Stacey R, Brittain K, Kerr S. Singing for health: An exploration of the issues. Health Educ 2002;102:156-62.  Back to cited text no. 13
    
14.
Higgins S, Hall E, Wall K, Woolner P, McCaughey C. The Impact of School Environments: A Literature Review; 2005. Available from: http://www.ncl.ac.uk/cfl at/news/DCReport.pdf. [Last accessed on 2016 Dec 20].  Back to cited text no. 14
    
15.
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.  Back to cited text no. 15
  [Full text]  
16.
Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: Updated guidelines for reporting parallel group randomised trials. BMC Med 2010;8:18.  Back to cited text no. 16
    
17.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.  Back to cited text no. 17
    
18.
Worthington HV, Hill KB, Mooney J, Hamilton FA, Blinkhorn AS. A cluster randomized controlled trial of a dental health education program for 10-year-old children. J Public Health Dent 2001;61:22-7.  Back to cited text no. 18
    
19.
Creeth JE, Gallagher A, Sowinski J, Bowman J, Barrett K, Lowe S, et al. The effect of brushing time and dentifrice on dental plaque removal in vivo. J Dent Hyg 2009;83:111-6.  Back to cited text no. 19
    
20.
Hogenesa M, Oersb BV, Diekstrac RF. The impact of music on child functioning. Eur J Soc Behav Sci 2014;10:1507-26.  Back to cited text no. 20
    

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Correspondence Address:
Dr. Nivedha Subburaman
Plot 4, Kubernagar Main Road, Opp 7th Street, Kubernagar Extension, Madipakkam, Chennai - 600 091, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_128_17

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