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Effect of Toothbrushing Application for Kids on Dental Plaque Removal and Interest in Toothbrushing of Preschool Children
J Dent Hyg Sci 2023;23:208-15
Published online September 30, 2023;  https://doi.org/10.17135/jdhs.2023.23.3.208
© 2023 Korean Society of Dental Hygiene Science.

Chae-Ha Hwang , Hyeon-Ju Song , Min-Ji Jung , Yeon-Jae Choi , and Young Sun Hwang†

Department of Dental Hygiene, College of Health Science, Eulji University, Seongnam 13135, Korea
Correspondence to: †Young Sun Hwang, https://orcid.org/0000-0001-7012-3434
Department of Dental Hygiene, College of Health Science, Eulji University, 553 Sanseong-daero, Sujeong-gu, Seongnam 13135, Korea
Tel: +82-31-740-7493, Fax: +82-31-740-7352, E-mail: kiteys@eulji.ac.kr
Received June 26, 2023; Revised August 3, 2023; Accepted August 10, 2023.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background: Dental caries in preschool children can cause early loss of teeth, reduced masticatory function, malocclusion, and speech disorders, making oral care for preschool children essential. However, because children have a poor ability to perform oral hygiene by themselves, educational tools that help establish correct oral health behaviors are required. This study evaluated the effect of toothbrushing application for kids on dental plaque removal and toothbrushing interest in preschool children.
Methods: Seven 5-year-old children enrolled in a daycare center participated in the evaluation, and the same children participated in the experiment twice a week. The Pokémon Smile application (App) was used as an auxiliary application for tooth brushing, and the degree of dental plaque removal on the tooth surface was evaluated by quantitative light-induced fluorescence-digital imaging. After the experiment, children’s toothbrushing preferences were investigated through interviews.
Results: The levels of AREA R30 and AREA R70 measured after the children’s toothbrushing as usual decreased compared to those before toothbrushing; however, the change was not significant. The levels of AREA R30 and AREA R70 measured after using the Pokémon Smile App were significantly reduced compared to those before toothbrushing. Children’s interest in brushing their teeth increased by 28.59% after using the Pokémon Smile App.
Conclusion: The toothbrushing application for kids effectively removes dental plaque by helping preschool children brush their teeth. It also increased preschool children’s interest in tooth brushing. Therefore, an oral health education application would be useful for children who need to develop correct oral care methods and habits.
Keywords : Dental caries, Dental plaque, Mobile applications, Oral hygiene, Toothbrushing
Introduction

1.Background

As a result of the 2021∼2022 Children’s Oral Health Survey conducted by the Korea Centers for Disease Control and Prevention, more than half of 12-year-old children experienced dental caries1). Early childhood caries (ECC), also known as baby bottle caries, is a multiple form of caries that occurs in infants and young children and is the leading cause of tooth loss2). ECC not only causes pain and tooth loss but also interferes with the normal eruption of permanent teeth, adversely affecting development, com-munication, appearance, self-esteem, school activities, and life quality3,4). Children with high rates of caries in the primary teeth also have high rates of caries in their per-manent teeth5). Most preschool children spend considerable time in daycare centers or kindergartens and receive various education. However, in-depth interviews with childcare teachers revealed that because of the large number of chil-dren they were in charge of, it was not possible to inter-vene in the children’s brushing after meals and snacks6). According to the 2021∼2022 Children’s Oral Health Survey, the rate of caries in 5-year-old children was 66.4%, a slight decrease (2.1%p) compared to that in 2018, and the pre-valence of dental caries decreased to 30.2% (3.7%p). The permanent caries experience rate in 12-year-old was 58.4%, a slightly increased (2.0%p) compared to that in 2018, and the permanent caries experience index increased slightly (0.1%p) to 1.941,7). The average caries experience index (the Decayed, Missing, and Filled Teeth [DMFT] index) of 5-year-old children in Korea, which was 2.79, 3.07, 3.42, and 3.41 in 2012, 2015, 2018, and 2021∼2022, respectively, is gradually increasing and is significantly higher than the average DMFT index of 1.6 by OECD country1,8). During the preschool period, children lay the foundation for lifelong health by establishing perceptions and behavioral health patterns. However, it is difficult for preschool children to perform careful oral care indepen-dently because of the immature development of their fine motor skill nerves9). At the age of 5 to 6 years, the first permanent teeth and first molars erupt and are in a mixed dentition period. Therefore, it is vital to learn the correct oral health management method.

2.Objectives

Play learning is the most appropriate way to facilitate young children’s behavioral development. Therefore, edu-cational applications (Apps) that combine play and learning have been integrated onto smart devices and used for various purposes10). Apps based on smart devices are effective learning tools because they can be used at any time and place desired by learners11). Various play education apps using smart devices have been developed to help satisfy curiosity and self-directed learning in oral health education for toddlers and young children. Oral health education using computer games was effective in improving children’s oral health knowledge12), and the usefulness of apps using smart devices as oral health education media was sugge-sted13). As a result of the perception survey on the apps for smart devices as oral health education media for young children, there was a high positive perception of using apps as oral health education media for young children. In addition, those who had experience using educational media for oral healthcare or had used apps for infants and young children had a higher intention to use apps14). Toddlers and young children are highly curious about videos with pictures and movements; therefore, videos are useful for improving their learning ability15). Pokémon Smile is an app that helps children learn how to toothbrush and has the highest number of downloads as of October 2022 among apps related to oral hygiene16). Motion graphics or live-action videos developed for oral care education are activities and simple educational guidelines that children follow; however, it is impossible to observe individual behavioral changes immediately. In addition, the effect of inducing interest that leads to changes in oral hygiene behavior is low. On the other hand, the Pokémon Smile App is a mobile game that teaches how to brush teeth using augmented reality (AR)16). Because this App recognizes the user’s movement through the smart device’s camera, it is possible to provide education that immediately reflects changes in individual behavior. In addition, directing this AR function through a Pokémon character, which children prefer, has a high interest-inducing effect that can lead to changes in oral hygiene behavior by allowing children to participate in the tooth brushing game.

In this study, the Pokémon Smile App was used as a toothbrushing education medium to evaluate the effecti-veness of dental plaque removal and changes in children’s interest in toothbrushing. This study aimed to understand the effect of AR video media on introducing toothbrushing education in young children.

Materials and Methods

1.Ethic statement

This study was approved by the Institutional Review Board of Eulji University (EU22-89). Written informed consent was obtained from all participants.

2.Study participants

Seven 5-year-old children enrolled in a daycare center were the participants, and the same children visited the laboratory twice a week to participate in the experiment. In this study, only the participants themselves and the chil-dren, with the consent of the participants’ parents and daycare center directors, participated in the experiment.

3.Measurement of dental plaque on tooth surface using quantitative light-induced fluorescence-digital imaging

The amount of dental plaque on the tooth surface was evaluated using quantitative light-induced fluorescence- digital imaging (QLF-D; AIOBIO, Seoul, Korea). All par-ticipants brushed their teeth after lunch and participated in the experiment 2 hours later. There were no specific findings in the oral cavity, and their dental status was not evaluated. All participants chewed caramel before the start of the experiment. After 5 minutes, the labial and buccal surfaces of the anterior and posterior teeth were photo-graphed using a Q-ray camera. Kids toothbrush stage 3 (for ages 5∼7, Oral-B; P&G, Seoul, Korea) was provided to all participants. In the first experiment, the participants brushed their teeth as usual for 3 minutes and rinsed with water three times. In the second experiment, the participants brushed their teeth for 3 minutes according to the instru-ctions of the Pokémon Smile App and then rinsed with water three times. After completing all procedures, the same tooth surface was photographed again using a Q-ray camera. The method, order, and time of tooth brushing followed the instructions provided by the Pokémon Smile App. Dental imaging was performed by the same researcher while the participant sat on a dental chair. The fluore-scence levels of Q-ray images were obtained using a QLF- D analysis program (QA2 1.23.0.0; Inspektor Research Systems BV, Amsterdam, Netherlands). The fluorescence intensity of the dental plaque on the tooth surface was evaluated using AREA R30 and AREA R70 values.

4.Interest in toothbrushing

Considering that the participants were young, their degree of interest in tooth brushing was evaluated using an interview method. The degree of interest in tooth brushing was eva-luated twice after the first and second experiments were com-pleted. Questions about the degree of interest in tooth bru-shing were as follows: like, neither like nor dislike, dislike.

5.Statistical analysis

Statistical analyses were performed using IBM SPSS 29.0.1.0 (IBM Corp., Armonk, NY, USA). The degree of fluorescence of the dental plaque on the tooth surface acco-rding to whether the Pokémon Smile App was used or not was analyzed using the Wilcoxon signed-rank test. The degree of interest in tooth brushing collected in the first and second experiments was analyzed by frequency and percen-tage. The results are expressed as the mean±standard devia-tion. A p-value ≤0.05 was considered statistically significant.

Results

1.Dental plaque removal effect by using the Pokémon Smile App

Seven participants in the study chewed caramel before the start of the experiment and measured the dental plaque on the tooth surface using a Q-ray camera 5 minutes later. In the first experiment, after brushing as usual, the residual dental plaque on the tooth surface was measured again using a Q-ray camera. In the second experiment, after brushing according to the instructions of the Pokémon Smile App, the remaining dental plaque on the tooth sur-face was measured using a Q-ray camera (Fig. 1A).

Fig. 1. Effect of using Pokémon Smile Application (App) on dental plaque removal on the tooth surface. (A) Detection of dental plaque on tooth surface using a Q-ray camera. Q-ray fluorescence images were obtained with and without using the Pokémon Smile App on the labial and buccal surfaces of the anterior and posterior teeth of the participants (n=7). (B) The degree of dental plaque was analyzed using the AREA R30 and AREA R70 values of Q-ray fluorescence images in the QA2 pro-gram. Their fluorescence intensity scores obtained with and without using the Pokémon Smile App were graphed. p-value was determined from Wilcoxon signed-rank test.

The effect of the Pokémon Smile App on removing den-tal plaque on tooth surface was evaluated by analyzing the AREA R30 and AREA R70 fluorescence intensities using the analysis program QA2 on the images acquired with the Q-ray camera (Fig. 1B). In the first experiment, the levels of AREA R30 and AREA R70 measured after toothbru-shing as usual were decreased compared to those before toothbrushing; however, the change was not significant. In the first experiment, the levels of AREA R30 and AREA R70 measured after brushing as usual (AREA R30, mean 4.8±7.23; AREA R70, mean 3.2±5.45) were decreased compared to those before brushing (AREA R30, mean 6.8±6.89; AREA R70, mean 3.8±4.65); however, the difference was not significant (∆AREA R30, p=0.080; ∆AREA R70, p=0.225). On the other hand, in the second experiment, the levels of AREA R30 and AREA R70 measured after using the Pokémon Smile App (AREA R30, mean 6.5±7.87; AREA R70, mean 4.1±6.02) were decreased compared to those before brushing (AREA R30, mean 9.7±11.3; AREA R70, mean 6.4±8.71), and the change in levels was statistically significant (∆AREA R30, p=0.018; ∆AREA R70, p=0.028).

2.Effect of using the Pokémon Smile App on tooth brushing interest

After completing the first and second experiments, the participants’ interest in toothbrushing was investigated through interviews (Table 1). In the interview, after brushing their teeth as usual, four participants liked brushing their teeth (57.14%) and two disliked it (28.58%). One parti-cipant did not like or dislike toothbrushing (14.28%). In the interview after toothbrushing, according to the instruc-tions in the Pokémon Smile App, no participants disliked toothbrushing. On the other hand, the number of partici-pants who liked tooth brushing was six (85.71%), two (28.58%) more than that in the first interview. Even after using the Pokémon Smile App, only one participant (14.29%) maintained that toothbrushing was neither liked nor disliked.

Children’s Interest in Toothbrushing according to the Use of the Pokémon Smile Application (App) (n=7/group)

Question No use App Use App
Like 4 (57.14) 6 (85.71)
Neither like nor dislike 1 (14.28) 1 (14.29)
Dislike 2 (28.58) 0 (0)

Values are presented as n (%).
Discussion

1.Interpretation

Deciduous teeth not only play an essential role in masti-cation and pronunciation but also maintain a place for the eruption of permanent teeth and help in normal jawbone development17). Primary dental caries often occurs before school age and are closely related to early tooth loss, mas-ticatory function deterioration, malocclusion, pronunciation disorder, and permanent dental caries5). Multifaceted edu-cation, including theoretical education and practice, is effective oral health education for preschool children18). The improvement of oral health knowledge of preschool children through theoretical education and practice reduced the dental plaque index and improved their oral hygiene status. As a result of preschool children’s oral hygiene management education using e-learning media, their oral health knowledge and oral hygiene management abilities improved19). E-learning education is a learning system that enables children to acquire necessary contents in the required amount according to their characteristics. Since play is suitable for behavioral development and learning in pre-schoolers, educational apps that combine smart devices with play have recently been released in the field of oral hygiene management10,20). Educational apps that combine smart devices are useful for self-directed learning, regard-less of time and place13). Preschool children are particu-larly curious about pictures and movements, so videos help improve their learning abilities15).

2.Comparison with previous studies

As smartphone use has become common, apps that edu-cate children on brushing their teeth are being released21). The Pokémon Smile App is ae spin-off mobile game for most users. This study evaluated the effect of educational apps in smart devices that help with toothbrushing learning in two aspects for preschool children aged 5 years. The first was the dental plaque removal effect of using the Pokémon Smile App, and the second was the change in the children’s interest in tooth brushing after using the Pokémon Smile App. The results of our experiment demonstrated that the toothbrushing education, which guides participants to do so themselves, was effective in removing dental plaque. The Pokémon Smile App was effective in removing dental plaque from the entire tooth surface because the Pokémon character equipped with the AR function recognizes the user’s current movements through the camera of the smart device and guides to the tooth that needs to be brushed next. As a result of QLF-D analysis, compared to the fluo-rescence intensities of AREA R30 and AREA R70 after toothbrushing without Pokémon Smile App, their fluore-scence intensities were significantly reduced with the use of Pokémon Smile App (∆AREA R30, p=0.018; ∆AREA R70, p=0.028). There is a high positive perception of using smartphone apps as an oral health education medium for preschool children, and those who have used smartphone apps are also more willing to use smartphone apps for oral health education media14). Oral care habits are formed through repeated practice of correct tooth brushing and awareness of the importance of oral healthcare from a young age18). Therefore, oral health education media, such as the Pokémon Smile App, will be effective for preschool children in learning how to brush their teeth independently. According to a survey on health education in childcare facilities, only 26.5% of institutions regularly provide health education, whereas 10.7% of childcare facilities do health education21). However, parents who visit childcare centers have high demands for health manage-ment education programs22). Smartphone Apps are expected to expand into oral health education and practice of various ages in the future.

In this study, the QLF-D fluorescence tool was used to detect dental plaque on tooth surfaces. QLF-D is a high- definition digital imaging device that precisely analyses images of the tooth surface23). It quantifies the location and amount of dental plaque by real-time fluorescence detection of porphyrin of oral microorganisms present in dental plaque. When used with the QLF-D analysis program, dental plaque that formed relatively recently was sensi-tively detected using the AREA R30 values, and more accumulated dental plaque was detected using the AREA R70 or AREA R120 values. During the experiment, the participating children could visually observe their dental plaques. During the experiment, the participating children could directly observe the dental plaque on their teeth; thus, they could immediately recognize their oral hygiene status and determine their toothbrushing performance. Tools of directly monitoring oral health can effectively improve children’s awareness of oral hygiene management and increase the frequency of practice. Children aged 6∼12 had significantly decreased Cariview scores after daily use of quantitative photo fluorescence Q-scan for 1 month24). In our study, by analyzing the degree of dental plaque removal using QLF-D, the levels of AREA R30 and AREA R70 were significantly reduced when using the Pokémon Smile App. The fluorescence of the AREA R120 region obtained from the participating children was not reflected in the QLF-D results of this study because of its low sen-sitivity. Compared to AREA R30 and AREA R70, AREA R120 was more sensitive to old dental plaque. Compared with adults, preschool children have fewer old dental pla-ques. Therefore, in a study that requires measurement of dental plaque in young participants, participants had moderate or high caries activity or dental plaque index24). In future dental biofilm management studies on young participants, it is necessary to select participants according to the purpose of the study and the evaluation tool.

In addition, we demonstrated that the use of the Pokémon Smile App had a significant effect on tooth brushing awa-reness among preschool children. The oral hygiene app, which recognizes participants’ toothbrushing behavior and guides them throughout the toothbrushing process, has positively changed children’s brushing awareness. Because infants cannot maintain oral health and prevent oral diseases on their own, motivation through repeated education and direct experience are needed, and oral health behavior change through oral health education should be made a habit25). Educational apps that use children’s preferred characters are expected to be particularly effective for young children who need to learn the correct toothbru-shing method and motivate them to brush their teeth. This is expected to help improve children’s oral care abilities.

3.Limitation

At the beginning of this study, ten 5-year-old children participated in Q-ray imaging. Three out of 10 partici-pating children withdrew their participation during the expe-riment due to fear of low-light spaces and dental chairs. In a study in which children participated directly, increasing familiarity before the experiment and reducing their fear of the dental treatment environment was necessary. There-fore, studies including more participants are needed to verify further the dental plaque removal effect according to whether the Pokémon Smile App was used or not.

4.Conclusions

In this study, we verified that the use of the Pokémon Smile App as a toothbrushing education medium was effe-ctive in removing dental plaque and increasing children’s interest in toothbrushing. Applications based on smart devices that stimulates interest and help children acquire positive behavior will be very useful for oral health edu-cation of children entering tooth brushing.

Acknowledgments

None.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Ethical Approval

Human experiment was approved by the Institutional Review Board (IRB) of Eulji University (approval No. EU22-89).

Author contributions

Conceptualization: Chae-Ha Hwang, Hyeon-Ju Song, Min-Ji Jung, Yeon-Jae Choi, and Young Sun Hwang. Experi-ments: Chae-Ha Hwang, Hyeon-Ju Song, Min-Ji Jung, and Yeon-Jae Choi. Data acquisition: Chae-Ha Hwang, Hyeon- Ju Song, Min-Ji Jung, Yeon-Jae Choi, and Young Sun Hwang. Formal analysis: Chae-Ha Hwang, Hyeon-Ju Song, Min-Ji Jung, Yeon-Jae Choi, and Young Sun Hwang. Fun-ding: Young Sun Hwang. Supervision: Young Sun Hwang. Writing-original draft: Chae-Ha Hwang, Hyeon-Ju Song, Min-Ji Jung, Yeon-Jae Choi, and Young Sun Hwang. Writing-review & editing: Young Sun Hwang.

Funding

This research was supported by Eulji University in 2023.

Data availability

The data is provided at the request of the corresponding author for reasonable reason.

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