Dental health education through the brushing ROBOTUTOR: A new learning experience.

AIM: In the present study, a new electronic model ROBOTUTOR was designed to compare the efficacy of different modes of dental health education for demonstration of the Bass toothbrushing technique and also to evaluate its efficacy with different modes of dental health education in patient understanding.
MATERIALS AND METHODS: Total 150 subjects were randomized into two groups, Group 1 (Questionnaire) and Group II (Investigators). Subjects with history of gingivitis and only mild periodontitis were included. Demonstration of Bass technique was given to each subject with the help of three different modes, i.e., ROBOTUTOR, clinician, and audio-video aids.
RESULTS: The result was evaluated in terms of effectiveness, ease of understanding, attraction, and recollection. In the present study, the best mode of education is clinician demonstration and the least effective one is the audio-video mode. In contrast, the ROBOTUTOR model was found to be more attractive than the other two.
CONCLUSION: Although demonstration by clinician is the best, it is time consuming and not feasible for community purpose. ROBOTUTOR would thus save clinician's chair side time and help in effective demonstration of the brushing technique.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Years of experimental research, clinical trials, and demonstration projects in different geographical and social settings have confirmed that effective removal of dental plaque is essential to maintain the dental and periodontal health throughout life.[1] Daily removal of the dental plaque retards gingival inflammation and supragingival plaque formation.[2] The preventive measures practiced by the people to maintain optimal oral health is a major concern of the dental profession. An essential element in a preventive dental program, for both the individual and the group, is a well-organized plaque control program.

Toothbrushing is the primary mechanical means for removing dental plaque, thereby assisting in the prevention of oral diseases.[3] Toothbrushing is the most commonly recommended and performed oral hygiene technique all over the world. Like all other basic things, brushing technique should also be demonstrated to the masses.[45] The most common technique used by uninstructed individuals is a horizontal scrubbing motion that engages the occlusal and buccal/lingual surfaces.[6] Effective plaque control can be achieved by introduction of the more advanced techniques of toothbrushing among the masses. In order to systemize the toothbrushing procedure, the techniques that have been suggested include Horizontal scrubbing, Roll technique, and Charters and Bass methods. There are no recent studies that compare toothbrushing methods. The original studies conducted were typically short-term, neither did they evaluate gingival health nor demonstrate one method as being consistently superior.[47] The Bass technique[8] was first described in 1954. In the past decade, it has become the method most frequently recommended method as it is easy to learn and emphasizes sulcular placement of bristles. The basic premise is to adapt the bristle tips to the gingival margin in order to reach the supragingival plaque, using controlled movement to avoid trauma and moving the brush systematically all around the teeth. It has been shown that proper use of The Bass technique three times a week will prevent the formation of subgingival plaque on buccal surfaces accessible to the toothbrush.[9]

Health education is the channel for reaching the people and is vital to the practice of prevention. A health educated person is well aware of his own responsibilities and the steps he himself must take to receive the full benefits of prevention at all levels.[10] Importance of oral health education and motivation can be shown by giving demonstration to the patient by actually doing the things, by reviewing, by repetition, or by motivating patients. Various aids in dental health education can be classified as Audio aids, Visual aids, projected aids (films, slides, overhead projectors), non-projected aids-(black board, pictures, posters, photographs, models), and Audio-visual aids (televisions, laptops, video cassette).[11]

“ROBOTUTOR” [Figure 1] is an audio-visual aid attempted to develop an electronic brushing model for demonstration of “The Bass method”[8] of toothbrushing.

Figure 1

ROBOTUTOR model image

Need to develop a brushing model-

Fatigue to the dentist because of continuous explanation of brushing techniques to the patients.

Limitations of projected aid such as computers, TV screens, etc.

As a Table top model to assist the dentist for, education and motivation of a patient.

ROBOTUTOR is assembled of

Programmed Robotic arm

3 stepper motor 12v D.C current

Circuit electronic chip comprising of transformer and integrated circuits

Upper-lower cast and tooth brush

Audio tape with speaker in a regional language

Working

Circuit electronic chip is controlled by micro-controlled program (software); the chip further manages the working of stepper motors attached to a robotic arm to which the tooth brush is attached. One audio tape in a regional language with speaker is connected to the main unit [Figure 2].

Figure 2

ROBOTUTOR model with its various components

Till date, there is no study in Literature which has compared the various modes of dental health education for the effective plaque control program. Therefore, the present study was conducted to evaluate the efficacy of a toothbrushing model. The aim of the present study was to compare the efficacy of different modes of dental health education for demonstration of the Bass tooth brushing technique with the following objectives:

To check which mode of brushing technique demonstration is effective.

To check the efficacy of different modes of dental health education in patient understanding.

MATERIALS AND METHODS

A total of 150 patients (Female - 83, male - 67; Mean age, 38±3.5 years) after screening and on signing the informed consent were selected from the outpatient department of Periodontology, Mahatma Gandhi Vidyamandir's KBH Dental College and hospital, Nashik, India.

Inclusion criteria: Systemically healthy patient diagnosed with gingivitis or mild chronic periodontitis without gingival recession were included in the study.

Exclusion criteria: Patients with impaired manual dexterity, patients with moderate and sever periodontitis, and patients with a history of recent periodontal surgery were excluded.

A simple random sampling without replacement was carried out by lottery method. The sample was divided into the following two groups:

Group I: (Questionnaire group)

Sixty subjects were demonstrated the Bass toothbrushing technique through three different modes of dental health education.

Demonstration by dentist

Audio-visual aid (projected - laptop)

Audio-visual aid (non projected - electronic brushing model)

A questionnaire was provided to the subjects to assess the efficacy of the above modes of dental health education.

Questionnaire

Which mode of health education do you find effective?

Which mode do you find easy to understand?

Which mode of brushing technique do you find attractive?

After a few days of demonstration, could you recollect the technique?

If yes, which mode of dental health education do you feel helped you in grasping the technique?

Group II: (Investigator group)

Ninety subjects were evaluated by the investigators on a 3-point scale:

Subject was unable to demonstrate the technique

Subject could demonstrate the technique partly

Subject could demonstrate the technique completely.

The subjects were asked to demonstrate the brushing technique to all the three investigators simultaneously, who would be unaware of the group to which that particular patient belonged.

Statistical analysis

Statistical analysis was performed by using SPSS 14 software program. Non-parametric test "Z test" was used for intergroup comparison to know which mode of dental health education is effective, attractive, or easy to recollect.

RESULTS

In the present study, the best mode of education was a clinician demonstration; and the least effective one, the Audio-Video mode (33>14>11). Twenty-five subjects believe that a clinician mode is easier to understand when compared with brushing ROBOTUTOR and Audio-Video aids. When attractiveness was compared, of 60, 26 subjects stated that Electronic model "ROBOTUTOR" was a more attractive and easy to recollect mode of brushing technique compared with clinician demonstration and audio-video mode. The results of the questionnaire showed that the demonstration by clinician is the best possible mode overall in terms of effectiveness, ease of understanding, while electronic model ROBOTUTOR was found to be more attractive and easy to recollect compared with the other modes [Table 1]. When intergroup comparison was done, the clinician demonstration mode of dental health education was found to be statistically significant (P<0.05) than the other two modes. Again, it has been found that ROBOTUTOR model was found to be more attractive, but it was not statistically significant [Table 2].

Table 1

Frequency distribution for the various modes of tooth brushing demonstration methods

Table 2

Intergroup comparison for collected data by using a non-parametric test (Z test)

Results obtained from investigators in Group 2 showed that 66% of clinician demonstration mode subjects understand the technique very well followed by non-projected (ROBOTUTOR model) mode followed by projected mode (laptop). The overall results show that clinician mode of dental health education is effective in grasping and demonstrating the technique. Model is not superior but effective compared with projected aid [Table 3].

Table 3

Frequency distribution among the various modes of health education, on the basis of 3-grade scaling in group 2

DISCUSSION

The normal toothbrushing practice adequately performed by anyone could be sufficient to control bacterial plaque. Bass method and Roll method are two of the most commonly recommended techniques for toothbrushing in dental practice.[9] Clinical reports have demonstrated the effectiveness of the Bass method. Several other studies compare the Bass method with other brushing techniques. Gibson and Wade[12] compared the effectiveness of Bass method and Roll technique in plaque removal, showing that Bass method was superior in cleaning the tooth tissue adjacent to gingival tissue of the facial and lingual aspects. Demonstration of proper brushing technique to the patient is an integral part of effective plaque removal and to prevent its accumulation on tooth surface. Patient can be educated with different modes of dental health education. Motion pictures, models, radio, newspapers, and exhibits are of distinct value and carry their message to a large numbers of people.[13]

Electronic model “ROBOTUTOR” was found to be more attractive and a better mode compared with projected aids (Laptop) and it has got significant implications for private as well as community motivation. Large number of population can be educated with correct method of toothbrushing. Result of the present study suggests that demonstration by the clinician on one to one basis has a greater impact and reinforcement of the brushing technique can be done through ROBOTUTOR at the subsequent visits. Again, the cost for manufacturing this ROBOTUTOR amounts to about Indian Rs. 15000.00 only and the space required is about 15×12×10 inches, which is quite small and can be easily accommodated in the dental office or waiting room. This aids in the education of the accompanying person as well. The time required for demonstration of a toothbrushing technique is about 1 minute.

Other than a major advantage of mass education, human error in technique demonstration could also be avoided. However, the ROBOTUTOR model demonstrates only a single technique and is unable to reproduce all the movements.

CONCLUSION

An extremely common mode of delivery of oral hygiene messages is the personal instructions approach in the clinical settings on one-to-one basis. Although demonstration by clinician is the best, it is time consuming and not feasible for community purpose. ROBOTUTOR would thus save clinician's chair side time as well as help in effective demonstration of the brushing technique. However, further long-term clinical trials should be carried out to conclude the efficacy of ROBOTUTOR machine in plaque control program.