Ó 2014 Eur J Oral Sci
Eur J Oral Sci 2014; 122: 142–148 DOI: 10.1111/eos.12113 Printed in Singapore. All rights reserved
European Journal of Oral Sciences
Effect of electric toothbrush on residents’ oral hygiene: a randomized clinical trial in nursing homes
Katrine G. Fjeld1, Morten Mowe2, Hilde Eide3, Tiril Willumsen1 1
Faculty of Dentistry, University of Oslo, Oslo; Medical Clinic, Institution of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo; 3Faculty of Health Sciences, Buskerud University College, Drammen, Norway
2
Fjeld KG, Mowe M, Eide H, Willumsen T. Effect of electric toothbrush on residents’ oral hygiene: a randomized clinical trial in nursing homes. Eur J Oral Sci 2014; 122: 142–148. © 2014 Eur J Oral Sci A single-blinded, randomized controlled clinical trial was performed to investigate the effect of electric toothbrushes (ET) compared with manual toothbrushes (MT) on residents in nursing homes and to evaluate the caregiver’s opinion on ET. A sample of 180 nursing-home residents were given either a new ET or a new MT. Oral examinations were performed to measure dental hygiene, using the Oral Hygiene Index-Simplified (OHI-S). Both groups received the same instructions for use. After 2 months participants were re-examined. Questionnaires were then sent to their caregivers. Participants’ mean age was 86.1 7.7 yr, and the mean number of remaining teeth was 20 5.6. No specific intervention effect was found for ET. Both groups showed identical improvements in the OHI-S, from 1.27 0.63 at baseline (the mean value for all participants) to 1.01 0.53 after 2 months. Of 152 caregivers who responded to the questionnaire, the majority evaluated ET to be beneficial and less time-consuming compared with MT, also for demented residents. In a frail population, no difference is found in the effect of ET compared with MT. However, the ET appears to be a useful aid for residents who receive assistance with dental hygiene.
The elderly population in developed countries is increasing rapidly (1). Despite improvements in medical care, age is still associated with reduced function, frailty, and increased susceptibility to morbidity. This leads to a complex variety of diagnoses and different needs for care in nursing homes. Several studies show correlations between general health and dental health (2–4). Life quality is an important factor in the last stages of life, and studies have shown positive associations between good dental health and life quality in the frail elderly (5, 6). To maintain good dental health, plaque control is essential (7). Residents in nursing homes are often dependent on caregivers who provide help with a variety of personal needs. Residents in nursing homes have a considerable need for oral health care, but oral hygiene has a low priority among care providers (8–10). Reports from Norway show that the number of remaining teeth in the elderly population is increasing (5, 11). Residents in nursing homes often have many natural teeth with exposed root surfaces, bifurcations, and a complexity of dental restorations, such as partial prostheses, bridges and crowns, fillings, and implants (12). In addition, many residents may have limited physical ability, such as reduced muscular strength (13). Hyposalivation, a common side effect of polypharmacy, contributes to make the frail elderly especially vulnerable to caries development and other
Katrine G. Fjeld, Department of Paediatric Dentistry and Behavioral Science, Faculty of Dentistry, University of Oslo, PO Box 1109, Blindern, NO-0317 Oslo, Norway E-mail: [email protected] Key words: caregiver; frail elderly; oral hygiene index; randomized clinical trial Accepted for publication December 2013
oral infections (14). Dental plaque is a contributing factor in the development of dental caries (14, 15), and the amount of dental plaque in nursing-home residents is shown to be significant (2, 7). All of these factors contribute to complicate the ability to maintain good oral hygiene, for both residents and their caregivers. Prevention of disease is an important principle in all medical treatment. The most important efforts for prevention of oral diseases are daily routines that safeguard oral hygiene, adjusted nutrition, and fluoride treatment (16, 17). Many clinical trials have focused upon the effect of electric toothbrushes (ET). In a Cochrane review from 2004 it was concluded that the use of ET is effective in removal of dental plaque (18). However none of the studies included only nursing-home residents in a randomized controlled clinical trial (RCT). There are reports from workers in nursing homes that approve ET as a helpful aid (19, 20), but there are no RCTs of the effect of ET on residents in nursing homes. Previous studies have encouraged more research in this area (20). Therefore, the primary aim of this study was to investigate the effect of ET compared with manual toothbrushes (MT) on dental plaque in a semi-blinded RCT-designed study, in a sample of nursing-home residents. To explore the clinical relevance further we wanted to know how caregivers evaluate the use of ET
Electric toothbrush in nursing homes
and to explore if assistance with ET had any effect on dental plaque. We hypothesized that ET would have a beneficial effect in this population.
Material and methods This study was a single-blinded RCT conducted in Norway between September 2011 and March 2012. The study population consisted of residents and caregivers in long-term care facilities in Oslo. A request to participate was posted by Utviklingssenter for sykehjem (Agency for Nursing Homes in the City of Oslo) to all nursing homes in Oslo. The first nine nursing homes to respond were included. Participant inclusion criteria were: at least six remaining natural teeth, admission to long-term care, and assessed by the head nurse to have stable health in the intervention period. A total of 233 subjects matched the inclusion criteria. Participants were excluded if they needed dental treatment with mouthwash rinse or gels containing plaque-inhibiting agents or if they, for any reason, were not able to perform normal oral-hygiene care. Physicians in the corresponding nursing homes decided, based on clinical judgment, whether participants were competent to give consent. Residents with severe cognitive impairment, for example as a result of advanced dementia, may not have the ability to express their opinion regarding participation. In those cases, we asked the closest relative to give consent. Nurses informed about the study and obtained informed written consent from participants or their relatives. All participants who gave consent were included in the study. Procedure For the purpose of ensuring quality control on procedures and plaque-score calibration, 20 nursing-home residents were examined before the RCT study. A pictorial series of teeth with different plaque scores was used to determine both interexaminer (j > 0.80) and intra-examiner (j > 0.80) reliability. A dentist and a dental hygienist performed all oral examinations. To secure participant’s integrity and privacy, clinical examinations were performed in their private room, with the participant sitting in his or her own chair, or lying on the bed. Oral assessments were performed using dental mirrors and a head lamp. Any need for dental treatment was referred to the corresponding dental clinic. The participants were randomly assigned to one of two groups directly after baseline assessment. Computerized and individual randomization was performed by an independent statistician. Both examiners were blinded with respect to group allocation. An independent dentist visited the nursing home 1–3 d after the baseline registrations, to give individual instructions to the patients and their nurses. All participants received the same instructions for use, orally and written in the form of illustrated instructional cards. Participants in the intervention group were instructed to use an electric, oscillating, rotating toothbrush (Oral-B Professional Care 1000; Oral-B, A division of Procter & Gamble, Weybridge, UK). Participants in the control group were instructed to use a manual toothbrush. The duration of the intervention period was 2 months.
143
All participants were given the same sodium fluoride toothpaste (containing 1450 p.p.m. F) and they were instructed to perform dental-hygiene procedures twice a day. This included brushing, interdental hygiene, and cleaning of dentures. Measures Background data were obtained from the nursing home’s files and from interviews with head nurses. Gender (male/female), age (yr), length of long-term care residency (months), medical data (number of medical diagnoses, number of prescription drugs), activities of daily life (ADL) functions, and cognitive status were recorded at baseline. Cognitive status [assessments rated as no, mild, moderate, or serious cognitive impairment (CI)] was evaluated by the physician in the respective nursing homes, based on different tests and examinations according to standardized procedures recommended by the government (21). Assistance with dental care (yes or no) was also recorded at baseline. Handgrip strength was assessed as a parameter of a resident’s medical condition (22). A Baseline Hydraulic Handgrip Dynamometer (model 120240; Fabrication Enterprises, White Plains, NY, USA) was used. Grip strength was measured in a seated position with the elbow flexed at 90°. Grip strength was measured three times for both arms. Median score (in pounds) was registered. The number of teeth and the presence of dental plaque were recorded. Oral dryness was reported as positive if the mirror slide-test (23) resulted in adhesion of the dental mirror to the buccal mucosa and if clinical inspection showed that the floor of the mouth lacked a normal saliva pool in addition to a dry and fissured tongue. The debris index (DI-S) from the Simplified Oral Hygiene Index (OHI-S) (24, 25) was used as a measure of dental hygiene. Six indicator teeth, usually 16, 26, 36, 46, 11, and 31, were used. If the indicator tooth was not present, the adjacent tooth was used. Each tooth was rated with a plaque score of 0–3. The mean score of the six indicator teeth represents the DI-S score. The cut-off points for the DI-S score, used to evaluate dental-hygiene quality, were rated as follows: 0–0.6, good dental-hygiene quality; 0.7–1.8, acceptable dental-hygiene quality; and >1.8, unacceptable dental-hygiene quality. As an additional measure of dental hygiene to include dentures and gingival inflammation, the mucosal plaque index (MPS) was used (26). The MPS is a clinical index that includes all teeth, dentures, and mucosal status, and is rated on a scale from 2 to 8 (2–4 is good; 5–6 is acceptable; and 7–8 is poor). Questionnaires were sent to all nine nursing homes after the intervention period. They were distributed at a routine staff meeting to all caregivers attended. Participation was anonymous and voluntary. Return of the questionnaires was considered as consent. The questionnaires consisted of questions with multiple-choice answers and the possibility to elaborate comments (Table S1). The questions were based on the study of WOLDEN et al. (18) for the purpose of revealing information of use, utility value, time consumption, and general opinion of the ET compared with the MT. The study was approved by the Regional Committee for Research Ethics in Norway. Statistical analysis All analyses were performed using SPSS, version 19 for Windows (SPSS, Chicago, IL, USA). Calibration was
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Fjeld et al.
(n = 115: 57 in the ET group and 58 in the MT group) had an acceptable OHI-S; and 22.2% (n = 40; 18 in the ET group and 22 in the MT group) had a poor OHI-S.
performed using j statistics. Continuous variables were presented as mean and SD, and binary variables as number and percentage. The independent-sample t-test was used to describe difference in OHI-S and MPS scores by analysing the mean values between the two primary groups. The chisquare test was used when comparing binary variables in two groups. Correlation for subgroup (with or without assistance) was tested with regression analyses. The Wilcoxon signed-rank test was used to describe differences in time distribution when using MT compared with ET. A regression analysis was used to test differences between groups regarding background variables. The limit for statistical significance was set at P < 0.05.
Change in plaque scores after the intervention period
There was a significant reduction in plaque, as measured by improvement of the plaque score in both groups after the intervention period. Of the participants, 163 (90.5%) had acceptable or good dental hygiene after 2 months. There was identical mean improvement in both groups (Table 2). Both ET and MT gave a significant mean improvement in the MPS score: 0.60 1.2 (mean SD) for ET and 0.55 1.3 for MT (P < 0.001). Of the 40 participants with a poor OHI-S at baseline, 30 (14 in the ET group and 16 in the MT group) improved their OHI-S to acceptable and in 10 (four in the ET group and six in the MT group) their OHI-S was unchanged. Of the 115 participants with acceptable OHI-S at baseline, in 25 (15 in the ET group and 10 in the MT group) the OHI-S was improved to good, in 83 (41 in the ET group and 42 in the MT group) the OHI-S was unchanged, and in seven (one in the ET group and six in the MT group) the OHI-S was changed to poor. Of the participants with a good OHI-S at baseline, the OHI-S was unchanged in 17 (six in the ET group and 11 in the MT group) and was changed to acceptable in eight (three in the ET group and five in the MT group). In a regression analysis with difference in the OHI-S as the dependent variable, the significant difference in OHI-S was sustained when controlling for OHI-S at baseline (t = 2.238, P = 0.028). After 2 months there was no significant difference in the OHI-S score in the
Results A total of 180 participants were included in the study. Their age ranged from 49 to 104 yr (mean age SD = 86.1 7.7 yr). Of the participants, 54.4% had ≥20 teeth. Participants with ≥20 teeth had a significantly better OHI-S score compared with participants with fewer than 20 teeth (1.17 0.62 vs. 1.40 0.65, respectively; P = 0.008). Mean handgrip strength for both male and female participants was low. For women, the mean SD score for the right hand was 17.9 11.6 and for the left hand was 16.7 10.9. For men, the mean SD score for the right hand was 36.4 19.8 and for the left hand was 32.5 21.9. Table 1 describes group distribution according to background variables. No significant differences were found between the two groups at baseline (P > 0.05). The mean SD baseline OHI-S score was 1.28 0.64 (range: 0.2- 3.0). There was no significant difference between the two groups at baseline (P > 0.05). At baseline, 13.9% (n = 25: 14 in the ET group and 11 in the MT group) had a good OHI-S; 63.9%
Table 1 Background variables according to group Toothbrush, type Variable No. of women Age (yr) Duration of nursing home residency (months) More than five medical diagnoses Impaired cognitive function* Number of prescription drugs Assistance with daily functions (i.e. dressing or washing) Always Sometimes Never Without dental-care assistance Number of natural teeth Mouth dryness Removable dentures† Used electric toothbrush before the study
Electric (N = 86)
Manual (N = 94)
All participants (N = 180)
62/86 (72.1) 87.0 7.3 23.8 22.6 33/83 (39.8) 49/85 (57.6) 5.7 3.4
73/94 (77.7) 85.2 8.0 25.8 22.9 30/91 (33.0) 43/94 (45.7) 5.7 3.1
135/180 (75.0) 86.1 7.7 24.8 22.7 63/174 (36.2) 92/179 (51.4) 5.7 3.2
61/86 (70.9) 18/86 (20.9) 7/86 (8.1) 60/86 (69.8) 20.1 5.5 11/86 (12.8) 16/86 (18.6) 4/86 (4.7)
71/94 (75.0) 15/94 (16.0) 8/94 (8.5) 72/94 (76.6) 20.3 5.8 11/94 (11.7) 18/94 (19.1) 8/94 (8.5)
132/180 (73.3) 33/180 (18.3) 15/180 (8.3) 132/180 (73.3) 20 5.6 22/180 (12.2) 34/180 (18.9) 14/180 (7.8)
Values are given as n/N (number of cases/number of observations; %) or mean SD. Some variables have missing data. *Moderate or serious cognitive impairment. † Number of participants with removable dentures.
Electric toothbrush in nursing homes
145
Table 2 Oral Hygiene Index-Simplified (OHI-S) score at baseline and after 2 months of intervention Intervention
OHI-S at baseline
OHI-S after 2 months
Difference in OHI-S
P
MT (n = 94) ET (n = 86)
1.31 0.66 1.23 0.59
1.05 0.54 0.97 0.51
0.26 0.54 0.26 0.52
Eur J Oral Sci 2014; 122: 142–148 DOI: 10.1111/eos.12113 Printed in Singapore. All rights reserved
European Journal of Oral Sciences
Effect of electric toothbrush on residents’ oral hygiene: a randomized clinical trial in nursing homes
Katrine G. Fjeld1, Morten Mowe2, Hilde Eide3, Tiril Willumsen1 1
Faculty of Dentistry, University of Oslo, Oslo; Medical Clinic, Institution of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo; 3Faculty of Health Sciences, Buskerud University College, Drammen, Norway
2
Fjeld KG, Mowe M, Eide H, Willumsen T. Effect of electric toothbrush on residents’ oral hygiene: a randomized clinical trial in nursing homes. Eur J Oral Sci 2014; 122: 142–148. © 2014 Eur J Oral Sci A single-blinded, randomized controlled clinical trial was performed to investigate the effect of electric toothbrushes (ET) compared with manual toothbrushes (MT) on residents in nursing homes and to evaluate the caregiver’s opinion on ET. A sample of 180 nursing-home residents were given either a new ET or a new MT. Oral examinations were performed to measure dental hygiene, using the Oral Hygiene Index-Simplified (OHI-S). Both groups received the same instructions for use. After 2 months participants were re-examined. Questionnaires were then sent to their caregivers. Participants’ mean age was 86.1 7.7 yr, and the mean number of remaining teeth was 20 5.6. No specific intervention effect was found for ET. Both groups showed identical improvements in the OHI-S, from 1.27 0.63 at baseline (the mean value for all participants) to 1.01 0.53 after 2 months. Of 152 caregivers who responded to the questionnaire, the majority evaluated ET to be beneficial and less time-consuming compared with MT, also for demented residents. In a frail population, no difference is found in the effect of ET compared with MT. However, the ET appears to be a useful aid for residents who receive assistance with dental hygiene.
The elderly population in developed countries is increasing rapidly (1). Despite improvements in medical care, age is still associated with reduced function, frailty, and increased susceptibility to morbidity. This leads to a complex variety of diagnoses and different needs for care in nursing homes. Several studies show correlations between general health and dental health (2–4). Life quality is an important factor in the last stages of life, and studies have shown positive associations between good dental health and life quality in the frail elderly (5, 6). To maintain good dental health, plaque control is essential (7). Residents in nursing homes are often dependent on caregivers who provide help with a variety of personal needs. Residents in nursing homes have a considerable need for oral health care, but oral hygiene has a low priority among care providers (8–10). Reports from Norway show that the number of remaining teeth in the elderly population is increasing (5, 11). Residents in nursing homes often have many natural teeth with exposed root surfaces, bifurcations, and a complexity of dental restorations, such as partial prostheses, bridges and crowns, fillings, and implants (12). In addition, many residents may have limited physical ability, such as reduced muscular strength (13). Hyposalivation, a common side effect of polypharmacy, contributes to make the frail elderly especially vulnerable to caries development and other
Katrine G. Fjeld, Department of Paediatric Dentistry and Behavioral Science, Faculty of Dentistry, University of Oslo, PO Box 1109, Blindern, NO-0317 Oslo, Norway E-mail: [email protected] Key words: caregiver; frail elderly; oral hygiene index; randomized clinical trial Accepted for publication December 2013
oral infections (14). Dental plaque is a contributing factor in the development of dental caries (14, 15), and the amount of dental plaque in nursing-home residents is shown to be significant (2, 7). All of these factors contribute to complicate the ability to maintain good oral hygiene, for both residents and their caregivers. Prevention of disease is an important principle in all medical treatment. The most important efforts for prevention of oral diseases are daily routines that safeguard oral hygiene, adjusted nutrition, and fluoride treatment (16, 17). Many clinical trials have focused upon the effect of electric toothbrushes (ET). In a Cochrane review from 2004 it was concluded that the use of ET is effective in removal of dental plaque (18). However none of the studies included only nursing-home residents in a randomized controlled clinical trial (RCT). There are reports from workers in nursing homes that approve ET as a helpful aid (19, 20), but there are no RCTs of the effect of ET on residents in nursing homes. Previous studies have encouraged more research in this area (20). Therefore, the primary aim of this study was to investigate the effect of ET compared with manual toothbrushes (MT) on dental plaque in a semi-blinded RCT-designed study, in a sample of nursing-home residents. To explore the clinical relevance further we wanted to know how caregivers evaluate the use of ET
Electric toothbrush in nursing homes
and to explore if assistance with ET had any effect on dental plaque. We hypothesized that ET would have a beneficial effect in this population.
Material and methods This study was a single-blinded RCT conducted in Norway between September 2011 and March 2012. The study population consisted of residents and caregivers in long-term care facilities in Oslo. A request to participate was posted by Utviklingssenter for sykehjem (Agency for Nursing Homes in the City of Oslo) to all nursing homes in Oslo. The first nine nursing homes to respond were included. Participant inclusion criteria were: at least six remaining natural teeth, admission to long-term care, and assessed by the head nurse to have stable health in the intervention period. A total of 233 subjects matched the inclusion criteria. Participants were excluded if they needed dental treatment with mouthwash rinse or gels containing plaque-inhibiting agents or if they, for any reason, were not able to perform normal oral-hygiene care. Physicians in the corresponding nursing homes decided, based on clinical judgment, whether participants were competent to give consent. Residents with severe cognitive impairment, for example as a result of advanced dementia, may not have the ability to express their opinion regarding participation. In those cases, we asked the closest relative to give consent. Nurses informed about the study and obtained informed written consent from participants or their relatives. All participants who gave consent were included in the study. Procedure For the purpose of ensuring quality control on procedures and plaque-score calibration, 20 nursing-home residents were examined before the RCT study. A pictorial series of teeth with different plaque scores was used to determine both interexaminer (j > 0.80) and intra-examiner (j > 0.80) reliability. A dentist and a dental hygienist performed all oral examinations. To secure participant’s integrity and privacy, clinical examinations were performed in their private room, with the participant sitting in his or her own chair, or lying on the bed. Oral assessments were performed using dental mirrors and a head lamp. Any need for dental treatment was referred to the corresponding dental clinic. The participants were randomly assigned to one of two groups directly after baseline assessment. Computerized and individual randomization was performed by an independent statistician. Both examiners were blinded with respect to group allocation. An independent dentist visited the nursing home 1–3 d after the baseline registrations, to give individual instructions to the patients and their nurses. All participants received the same instructions for use, orally and written in the form of illustrated instructional cards. Participants in the intervention group were instructed to use an electric, oscillating, rotating toothbrush (Oral-B Professional Care 1000; Oral-B, A division of Procter & Gamble, Weybridge, UK). Participants in the control group were instructed to use a manual toothbrush. The duration of the intervention period was 2 months.
143
All participants were given the same sodium fluoride toothpaste (containing 1450 p.p.m. F) and they were instructed to perform dental-hygiene procedures twice a day. This included brushing, interdental hygiene, and cleaning of dentures. Measures Background data were obtained from the nursing home’s files and from interviews with head nurses. Gender (male/female), age (yr), length of long-term care residency (months), medical data (number of medical diagnoses, number of prescription drugs), activities of daily life (ADL) functions, and cognitive status were recorded at baseline. Cognitive status [assessments rated as no, mild, moderate, or serious cognitive impairment (CI)] was evaluated by the physician in the respective nursing homes, based on different tests and examinations according to standardized procedures recommended by the government (21). Assistance with dental care (yes or no) was also recorded at baseline. Handgrip strength was assessed as a parameter of a resident’s medical condition (22). A Baseline Hydraulic Handgrip Dynamometer (model 120240; Fabrication Enterprises, White Plains, NY, USA) was used. Grip strength was measured in a seated position with the elbow flexed at 90°. Grip strength was measured three times for both arms. Median score (in pounds) was registered. The number of teeth and the presence of dental plaque were recorded. Oral dryness was reported as positive if the mirror slide-test (23) resulted in adhesion of the dental mirror to the buccal mucosa and if clinical inspection showed that the floor of the mouth lacked a normal saliva pool in addition to a dry and fissured tongue. The debris index (DI-S) from the Simplified Oral Hygiene Index (OHI-S) (24, 25) was used as a measure of dental hygiene. Six indicator teeth, usually 16, 26, 36, 46, 11, and 31, were used. If the indicator tooth was not present, the adjacent tooth was used. Each tooth was rated with a plaque score of 0–3. The mean score of the six indicator teeth represents the DI-S score. The cut-off points for the DI-S score, used to evaluate dental-hygiene quality, were rated as follows: 0–0.6, good dental-hygiene quality; 0.7–1.8, acceptable dental-hygiene quality; and >1.8, unacceptable dental-hygiene quality. As an additional measure of dental hygiene to include dentures and gingival inflammation, the mucosal plaque index (MPS) was used (26). The MPS is a clinical index that includes all teeth, dentures, and mucosal status, and is rated on a scale from 2 to 8 (2–4 is good; 5–6 is acceptable; and 7–8 is poor). Questionnaires were sent to all nine nursing homes after the intervention period. They were distributed at a routine staff meeting to all caregivers attended. Participation was anonymous and voluntary. Return of the questionnaires was considered as consent. The questionnaires consisted of questions with multiple-choice answers and the possibility to elaborate comments (Table S1). The questions were based on the study of WOLDEN et al. (18) for the purpose of revealing information of use, utility value, time consumption, and general opinion of the ET compared with the MT. The study was approved by the Regional Committee for Research Ethics in Norway. Statistical analysis All analyses were performed using SPSS, version 19 for Windows (SPSS, Chicago, IL, USA). Calibration was
144
Fjeld et al.
(n = 115: 57 in the ET group and 58 in the MT group) had an acceptable OHI-S; and 22.2% (n = 40; 18 in the ET group and 22 in the MT group) had a poor OHI-S.
performed using j statistics. Continuous variables were presented as mean and SD, and binary variables as number and percentage. The independent-sample t-test was used to describe difference in OHI-S and MPS scores by analysing the mean values between the two primary groups. The chisquare test was used when comparing binary variables in two groups. Correlation for subgroup (with or without assistance) was tested with regression analyses. The Wilcoxon signed-rank test was used to describe differences in time distribution when using MT compared with ET. A regression analysis was used to test differences between groups regarding background variables. The limit for statistical significance was set at P < 0.05.
Change in plaque scores after the intervention period
There was a significant reduction in plaque, as measured by improvement of the plaque score in both groups after the intervention period. Of the participants, 163 (90.5%) had acceptable or good dental hygiene after 2 months. There was identical mean improvement in both groups (Table 2). Both ET and MT gave a significant mean improvement in the MPS score: 0.60 1.2 (mean SD) for ET and 0.55 1.3 for MT (P < 0.001). Of the 40 participants with a poor OHI-S at baseline, 30 (14 in the ET group and 16 in the MT group) improved their OHI-S to acceptable and in 10 (four in the ET group and six in the MT group) their OHI-S was unchanged. Of the 115 participants with acceptable OHI-S at baseline, in 25 (15 in the ET group and 10 in the MT group) the OHI-S was improved to good, in 83 (41 in the ET group and 42 in the MT group) the OHI-S was unchanged, and in seven (one in the ET group and six in the MT group) the OHI-S was changed to poor. Of the participants with a good OHI-S at baseline, the OHI-S was unchanged in 17 (six in the ET group and 11 in the MT group) and was changed to acceptable in eight (three in the ET group and five in the MT group). In a regression analysis with difference in the OHI-S as the dependent variable, the significant difference in OHI-S was sustained when controlling for OHI-S at baseline (t = 2.238, P = 0.028). After 2 months there was no significant difference in the OHI-S score in the
Results A total of 180 participants were included in the study. Their age ranged from 49 to 104 yr (mean age SD = 86.1 7.7 yr). Of the participants, 54.4% had ≥20 teeth. Participants with ≥20 teeth had a significantly better OHI-S score compared with participants with fewer than 20 teeth (1.17 0.62 vs. 1.40 0.65, respectively; P = 0.008). Mean handgrip strength for both male and female participants was low. For women, the mean SD score for the right hand was 17.9 11.6 and for the left hand was 16.7 10.9. For men, the mean SD score for the right hand was 36.4 19.8 and for the left hand was 32.5 21.9. Table 1 describes group distribution according to background variables. No significant differences were found between the two groups at baseline (P > 0.05). The mean SD baseline OHI-S score was 1.28 0.64 (range: 0.2- 3.0). There was no significant difference between the two groups at baseline (P > 0.05). At baseline, 13.9% (n = 25: 14 in the ET group and 11 in the MT group) had a good OHI-S; 63.9%
Table 1 Background variables according to group Toothbrush, type Variable No. of women Age (yr) Duration of nursing home residency (months) More than five medical diagnoses Impaired cognitive function* Number of prescription drugs Assistance with daily functions (i.e. dressing or washing) Always Sometimes Never Without dental-care assistance Number of natural teeth Mouth dryness Removable dentures† Used electric toothbrush before the study
Electric (N = 86)
Manual (N = 94)
All participants (N = 180)
62/86 (72.1) 87.0 7.3 23.8 22.6 33/83 (39.8) 49/85 (57.6) 5.7 3.4
73/94 (77.7) 85.2 8.0 25.8 22.9 30/91 (33.0) 43/94 (45.7) 5.7 3.1
135/180 (75.0) 86.1 7.7 24.8 22.7 63/174 (36.2) 92/179 (51.4) 5.7 3.2
61/86 (70.9) 18/86 (20.9) 7/86 (8.1) 60/86 (69.8) 20.1 5.5 11/86 (12.8) 16/86 (18.6) 4/86 (4.7)
71/94 (75.0) 15/94 (16.0) 8/94 (8.5) 72/94 (76.6) 20.3 5.8 11/94 (11.7) 18/94 (19.1) 8/94 (8.5)
132/180 (73.3) 33/180 (18.3) 15/180 (8.3) 132/180 (73.3) 20 5.6 22/180 (12.2) 34/180 (18.9) 14/180 (7.8)
Values are given as n/N (number of cases/number of observations; %) or mean SD. Some variables have missing data. *Moderate or serious cognitive impairment. † Number of participants with removable dentures.
Electric toothbrush in nursing homes
145
Table 2 Oral Hygiene Index-Simplified (OHI-S) score at baseline and after 2 months of intervention Intervention
OHI-S at baseline
OHI-S after 2 months
Difference in OHI-S
P
MT (n = 94) ET (n = 86)
1.31 0.66 1.23 0.59
1.05 0.54 0.97 0.51
0.26 0.54 0.26 0.52
