|Year : 2016 | Volume
| Issue : 2 | Page : 110-115
Effect of using an intra-oral camera as a reinforcement tool for plaque control in a supervised toothbrushing program: An interventional study
Priyanka Machale1, Sahana Hegde-Shetiya2, Pradnya Kakodkar2, Ravi Shirahatti2, Deepti Agarwal2, Saurabh Kakade3
1 Department of Public Health Dentistry, MGM Dental College and Hospital, Mumbai, Maharashtra, India
2 Department of Public Health Dentistry, Dr. D. Y. Patil Vidyapeeth, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune, India
3 Department of Public Health Dentistry, Bharati Vidyapeeth Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||10-Jun-2016|
Department of Public Health Dentistry, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Supervised toothbrushing program at schools have indicated limited improvement in oral hygiene among children. Aim: The aim of this study is to evaluate whether the use of an intra-oral camera as a reinforcement tool in a supervised tooth brushing program at school can improve plaque control. Materials and Methods: A double-blind, parallel, two arm interventional study was conducted among 120 school children from 2 schools, aged 12-year in Pune. The study group received an intervention of supervised toothbrushing and reinforcement sessions for 30 days using intra-oral camera. The control group received only supervised toothbrushing. Evaluation for plaque control was performed at the end of 30 days, 3 months, 6 months, and 12 months. Analysis of co-variance was used to find the intergroup difference at different time intervals. Analysis of variance was used to find the intragroup differences of the plaque scores. Post hoc Bonferroni test was used to find the pairwise changes in plaque scores between different time intervals. Results: In the study group, the mean plaque score was reduced to a significant extent from baseline to 30 days and 3 months (P < 0.05) and then the plaque score remained stable until the end of 12 months. While in the control group, the plaque score increased compared to baseline. There was a statistically significant difference between the mean plaque scores of study and control group at each time interval (P < 0.05). Conclusion: Intra-oral camera can be effectively used as a reinforcement tool in supervised toothbrushing program at school for achieving higher plaque reduction.
Keywords: Child, dental plaque, India, schools, toothbrushing
|How to cite this article:|
Machale P, Hegde-Shetiya S, Kakodkar P, Shirahatti R, Agarwal D, Kakade S. Effect of using an intra-oral camera as a reinforcement tool for plaque control in a supervised toothbrushing program: An interventional study. J Indian Assoc Public Health Dent 2016;14:110-5
|How to cite this URL:|
Machale P, Hegde-Shetiya S, Kakodkar P, Shirahatti R, Agarwal D, Kakade S. Effect of using an intra-oral camera as a reinforcement tool for plaque control in a supervised toothbrushing program: An interventional study. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Oct 15];14:110-5. Available from: http://www.jiaphd.org/text.asp?2016/14/2/110/183807
| Introduction|| |
Oral health-related interventions through schools can improve the child's oral health and oral health behavior. Removal of dental plaque by toothbrushing is one of the measures that the children can undertake to reduce dental diseases. Studies conducted on supervised tooth brushing program at schools can be retrieved from the literature, but their result indicates limited improvement in oral hygiene., This finding is probably because the children neither practiced what they had learnt at school, as their teacher did not impart the required skill needed for effective toothbrushing, nor were they supported at home., The systematic review on oral health interventions concluded, that school-based educational programs had a small positive but temporary effect on plaque level, even when daily brushing at school was part of the program.
If the toothbrushing program is based on the principles  of learning by doing, reinforcement, and repetition of what is being taught to them, then it may be possible that the children establish correct toothbrushing habits and thus result in improvement of their oral hygiene., It has been found that a heightened understanding of oral hygiene is necessary for greater compliance.
Hence, if supervised toothbrushing (learning by doing) is combined with displaying the plaque retention sites in the mouth using an intra-oral camera (reinforcement tool) and this exercise is repeated for 30 days (repetition), then indeed remarkable, prolonged, and permanent results may be visible.
Therefore, the purpose of this study was to evaluate whether use of an intra-oral camera as a reinforcement tool in a supervised toothbrushing program at school can improve plaque control among 12-year-old school children from Pune.
| Materials and Methods|| |
This was a double-blind, parallel, two-arm interventional study [Figure 1]. The study was carried out for 1 year from March 2011 to March 2012. The sample size for the study was determined using N master software version 1.0 (Christian Medical College, Vellore, Tamil Nadu, India) based on the previous study findings of Worthington et al. The minimum required sample size was estimated to be 46 children per school (Power 90%, alpha error 5%, two-sided), but to compensate for attrition, the sample size in both the groups was further increased to 15% and rounded off to 60 children per group. A list of Unaided English medium private schools for Pimpri-Pune India was drawn and two schools were randomly selected which were further allocated randomly into the study (Blossom Public School, Chinchwad) and control (Global Public School, Pimpri) group. These schools did not have any history of school dental programs. The study protocol was approved by the scientific and Institutional Ethics committee. Informed consent was obtained from their parents before starting the study.
One hundred and twenty, children aged 12 years participated in the study. Those children having <20 teeth, partially erupted teeth, teeth with surface lost because of caries, clinically detectable gingival inflammation and periodontal disease, undergoing orthodontic treatment and suffering from systemic diseases, mental or physical disabilities were excluded from the study.
The clinical examination was performed to record baseline plaque scores using Turesky-Gilmore-Glickman modification of Quigly Hein plaque index, 1970. Before commencing the study, the examiner (SK), underwent training and calibration for index recording on 10 subjects. The intra-class correlation coefficient was found to be 0.89. Blinding was ensured. The children were blinded to the kind of intervention and a blinded examiner (SK) evaluated the plaque scores of the children. The examination of children was carried out in concerned school premises, under natural daylight conditions with subjects seated comfortably on a chair with backrest and the examiner standing behind the subjects. The author (PM) trained herself for using the USB intra-oral camera (CAMMY, Dentamerica ®) to standardize its application by reading the instruction manual and practicing on 5 children in the Department Clinic.
Initially, a pilot study was performed on 6 children (10% of the sample size) over a period of 1 week to identify any organizational problems, and to check the feasibility with the use of intra-oral camera.
Sequence of events: (1) Study group: Baseline plaque score recording, basic introduction, supervised tooth brushing and reinforcement with intra-oral camera. (2) Control group: Baseline plaque score recording, basic introduction, and supervised tooth brushing.
The author (PM) provided basic introduction to both the groups through the means of Electronic media (Power-Point presentation), which was prepared as per contents given by Dunning (1978).
Taking one child at a time, in the presence of their parent, disclosing solution was applied on all the teeth surfaces, and plaque retentive sites were revealed to the child and parent with the help of the intra-oral camera. Then, supervised toothbrushing using Bass method was conducted. Then disclosing agent was applied again and the cleaned teeth surfaces were shown. In case, any plaque was retained, then the child was instructed to brush in that area. This exercise was done for every child individually in the presence of their parent on the 1st day only. From the 2nd day to the next 30 days (excluding Sunday), supervised toothbrushing was conducted in two batches. 30 children at a time in one batch and reinforcement with intra-oral camera on two different children every day.
On the 1st day, taking one child at a time in the presence of their parent, supervised toothbrushing using Bass method was conducted. This exercise was done for every child individually. From the 2nd day to the next 30 days (excluding Sunday), supervised toothbrushing was conducted in two batches with 30 children at a time in one batch.
All the parents were instructed to monitor toothbrushing at home. At the end of 30 days, the intervention was stopped. First evaluation of plaque scores was done at the end of 30 days. Third evaluation happened at the end of 6 months followed by the fourth at the end of 12 months.
SPSS Version 15.0 software was used to analyze data. Analysis of co-variance was used to find the statistical difference between study and control group at the end of 30 days, 3 months, 6 months and 12 months of intervention using baseline plaque scores as covariate. Repeated measures analysis of variance (ANOVA) was used to find the intra-group differences of the plaque scores. Post hoc Bonferroni test was used to find the pair-wise changes in plaque scores between different time intervals. Level of significance was fixed at 5%.
| Results|| |
Of the 120 children, selected for the study only 112 reached completion [Figure 2]. The mean plaque scores of study and control group are presented in [Table 1]. The intergroup comparison for the mean plaque scores shows a statistically significant difference at different time periods. The repeated measures ANOVA test [Table 2] suggests that there was statistically significant difference in the mean plaque score from baseline to 12 months in both study and the control group (P< 0.05). The post hoc Bonferroni test [Table 3] suggests that, in the study group, the plaque scores significantly differed from baseline up to 12 months and from 30 days up to 12 months (P< 0.05). After 3 months, there was no difference up to 12 months (P > 0.05). Whereas, in the control group, the plaque scores were significantly different from baseline up to 12 months, (P< 0.05), between 30 days and 3 months no significant difference was noted, but difference was noted thereafter. While, after 3 months up to 12 months, significant difference was noted.
|Table 1: Intergroup comparison of plaque scores among study and control at different time period|
Click here to view
|Table 2: Intragroup comparison of plaque scores within the study and control group at different time period|
Click here to view
|Table 3: Post hoc Bonferroni test (pair wise comparison of plaque scores between different time intervals|
Click here to view
In the study group, the percentage of plaque reduction from baseline to 30 days was 23.03% and then it remained stable at 23.87% until the end of 12 months. Whereas in the control group, the plaque reduction from baseline to the end of 30 days was 11.11%; 10.82% at the end 3 months, 6.26% at the end of 6 months and 3.27% at the end of 12 months.
| Discussion|| |
This study results indicate that the intra-oral camera can be used as an effective tool for reinforcement in supervised toothbrushing at school for plaque reduction. This finding is in consensus with the study conducted by Willershausen et al. who demonstrated that the intra-oral camera can effectively augment oral hygiene instruction and help create improvements in patient compliance.
In this study, maximum plaque reduction happened at the first follow-up (30 days), more in the study group as compared to the control group. The probable reason for positive finding was the on-going active reinforcement with the intra-oral camera. During the second follow-up (end of 3 months), overall, the plaque score was lower in both the groups compared to baseline but significantly lower in only the study group as compared to the 30 days score [Table 2]. This shows that the plaque-reducing effect was still sustainable in the study group when compared to that of control group. The first supervised toothbrushing session for every child individually was conducted in the presence of the parent, so that they can motivate the children at home. Rayner  has found that dental education given to parents was associated with improvement in oral hygiene of children, which was maintained during the summer holiday and the beneficial effect of the school based brushing program alone relapsed during the holiday. Since such parental influence was not evaluated in the study, if their motivation and guidance played a role, cannot be commented. However, this auxiliary finding is that parents can act as home motivators for their children regarding oral health needs to be researched in the future studies.
At the end of 6 and 12 months: In the study group, the plaque score had stabilized whereas in control group, it showed a significant increasing trend. Few authors believe that improvement in oral health resulting from an educational, preventive program was temporary.,,, Such phenomenon was not seen in this study. The study group results are indeed astonishing and promising. After 30 days of active intervention, there was no contact with the students, and also, there was no scope that the child would come prepared with clean teeth on the day of follow-up examination as it was a surprise check. Hence, it can be established that reinforcement sessions of supervised toothbrushing using intra-oral camera may have helped children in understanding plaque retention sites and develop toothbrushing practice, and this knowledge was sufficiently instilled in the minds of the children, that the beneficial effects were visible and retained until the end of 12 months. This finding is supported by a study Antonio et al., in their supervised toothbrushing program and reinforcement by the educational activities found that even after suspension of educational activities; there was no loss of the previously achieved benefits.
Intra-oral camera has found its use in tooth color assessment, intraoral photographic examination method for epidemiological surveillance of dental caries,, as a tool to illustrate oral hygiene instruction, intra-oral caries detection, second opinion, restorative treatment decision-making, newer technology by NewZealand dentist  and now as a reinforcement tool in supervised toothbrushing program.
The two randomly selected schools were located 6 Kilometers away from each other and hence, the “contamination effect” was avoided. The overall sample was homogenous as they belonged to the same socioeconomic strata. Twelve years old were selected because during this stage of childhood to adolescence, health behavior consolidates and probably will not change beyond adolescence  and all the habits learned during this time can be retained for lifelong. Blinding of examiner had lessened the chances of potential bias during plaque score recording. Collectively all these factors ensured high internal validity of the study.
Some of the limitations of school-based dental programs cannot be ignored. School oral health programs are not a one-time affair. Acquiring a good oral habit needs repeated reminders and motivation. Sometimes the school authorities refuse to allocate time for such activities since they are tightly packed with their own academic calendar.
| Conclusion|| |
The results of this study indicate that the use of intra-oral camera as a reinforcement tool in supervised toothbrushing sessions had an effect on reducing the plaque, and the plaque scores remained lower until the end of 12 months.
The use of intra-oral camera needs to be widely promoted for educating oneself about their oral health. The school oral health programs should integrate the use of intra-oral camera during oral screening, educating, and motivating the children. Intra-oral camera is easily available, is not costly and a nondental personnel can also use it. This device can be connected to one of the computers in the school laboratory. It is easier to motivate the person when he can actually visualize the plaque retentive sites rather than when only theoretical explanation is given.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Oral health promotion: An essential element of a health-promoting school. WHO information series on school health document eleven. Geneva: World Health Organization; 2003.
Kelder SH, Perry CL, Klepp KI, Lytle LL. Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors. Am J Public Health 1994;84:1121-6.
Sprod A, Anderson R, Treasure E. Effective Oral Health Promotion. Literature Review. Cardiff: Health Promotion Wales; 1996.
van Palenstein Helderman WH, Munck L, Mushendwa S, van't Hof MA, Mrema FG. Effect evaluation of an oral health education programme in primary schools in Tanzania. Community Dent Oral Epidemiol 1997;25:296-300.
Kay E, Locker D. A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dent Health 1998;15:132-44.
Peter S. Health education. In: Essentials of Preventive and Community Dentistry. 3rd
ed. India: Arya (Medi) Publishing House; 2001. p. 581-2.
Emler BF, Windchy AM, Zaino SW, Feldman SM, Scheetz JP. The value of repetition and reinforcement in improving oral hygiene performance. J Periodontol 1980;51:228-34.
Suomi JD, Peterson JK, Matthews BL, Voglesong RH, Lyman BA. Effects of supervised daily dental plaque removal by children after 3 years. Community Dent Oral Epidemiol 1980;8:171-6.
Willershausen B, Schlösser E, Ernst CP. The intra-oral camera, dental health communication and oral hygiene. Int Dent J 1999;49:95-100.
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.
Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of Victamine C. J Periodontol 1970;41:41-3.
Dunning JM. Dental health education. In: Principles of Dental Public Health. 3rd
ed. US: Harvard University Press; 1978. p. 370-1.
Rayner JA. A dental health education programme, including home visits, for nursery school children. Community Dent Health 1992;172:57-62.
Agerbaek N, Melson B, Lind O, Lavind L, Kristiansen B. Effect of regular small group instruction per se
on oral health status of Danish schoolchildren. J Periodontol 1979;7:17-20.
Frencken JE, Borsum-Andersson K, Makoni F, Moyana F, Mwashaenyi S, Mulder J. Effectiveness of an oral health education programme in primary schools in Zimbabwe after 3.5 years. Community Dent Oral Epidemiol 2001;29:253-9.
Ivanovic M, Lekic P. Transient effect of a short-term educational programme without prophylaxis on control of plaque and gingival inflammation in school children. J Clin Periodontol 1996;23:750-7.
Antonio AG, Kelly A, Valle DD, Vianna RB, Quintanilha LE. Long-term effect of an oral health promotion program for schoolchildren after the interruption of educational activities. J Clin Pediatr Dent 2007;32:37-41.
Lasserre JF, Pop-Ciutrila IS, Colosi HA. A comparison between a new visual method of colour matching by intraoral camera and conventional visual and spectrometric methods. J Dent 2011;39 Suppl 3:e29-36.
Boye U, Pretty IA, Tickle M, Walsh T. Comparison of caries detection methods using varying numbers of intra-oral digital photographs with visual examination for epidemiology in children. BMC Oral Health 2013;13:6.
Theocharopoulou A, Lagerweij MD, van Strijp AJ. Use of the ICDAS system and two fluorescence-based intraoral devices for examination of occlusal surfaces. Eur J Paediatr Dent 2015;16:51-5.
Forgie AH, Pine CM, Pitts NB. The assessment of an intra-oral video camera as an aid to occlusal caries detection. Int Dent J 2003;53:3-6.
Gambino O, Lima F, Pirrone R, Ardizzone E, Campisi G, di Fede O. A teledentistry system for the second opinion. Conf Proc IEEE Eng Med Biol Soc 2014;2014:1378-81.
Erten H, Uçtasli MB, Akarslan ZZ, Uzun O, Semiz M. Restorative treatment decision making with unaided visual examination, intraoral camera and operating microscope. Oper Dent 2006;31:55-9.
Tay KI, Wu JM, Yew MS, Thomson WM. The use of newer technologies by New Zealand dentists. N
Z Dent J 2008;104:104-8.
Albandar JM, Buischi YA, Mayer MP, Axelsson P. Long-term effect of two preventive programs on the incidence of plaque and gingivitis in adolescents. J Periodontol 1994;65:605-10.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]