Self-monitoring to improve home-based oral hygiene in seniors
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RESEARCH ORIGINAL ARTICLE 111
Hüsamettin Günay, Karen Meyer-Wübbold
Self-monitoring to improve home-
based oral hygiene in seniors
Introduction: In order to achieve an optimal brushing result when perform-
ing self-responsible home-based oral hygiene, patients should be able to self-
monitor both their brushing process and the cleaning result. This pilot study
conducted in cross-over design aimed to determine if an app or an abacus can
aid patients in implementing the “CIOTIPlus” tooth brushing system and
technique when performing self-responsible home-based oral hygiene.
Methods: Sixteen participants (8 female, 8 male; average age: 72.6 ± 4.2 years)
were included in the study. The study was divided into 3 phases. In each
phase, a different tool (self-developed app or “CIOTIPlus-Abacus”) was used to
support self-monitor home-based oral hygiene. In the baselinel examination
(t0), in addition to the general anamnesis, the DMF-T/S and PSI, QHI and
mAPI were recorded. The participants recorded their home-based oral hygiene
for 3 weeks by noting the cleaned tooth surfaces/areas in each phase. In
phase 1 (t1), the documentation was performed solely by using the app. In
phase 2 (t2), the documentation ensued through the use of the app as well,
but in contrast to t1, more functions were accessible on the app. In phase 3
(t3), the daily home-based oral hygiene was recorded using an abacus (“CIOTI-
Plus-Abacus”). The participants were also asked to fill out a questionnaire at
t0, t2 and t3.
Results: In the basic examination (t0), the participants showed an average
QHIt0 of 2.1 ± 0.7 and an average mAPIt0 of 3.5 ± 0.6. At t1, the subjects
showed significantly lower plaque-index values (PI values) in the area of the
smooth and proximal surfaces (QHIt1 1.6 ± 0.6; p = 0.004; mAPIt1 2.9 ± 0.7;
p = 0.003). At time t2, compared to t0 and t1, the average PI values were again
significantly lower in the area of both the smooth (QHIt2 0.8 ± 0.4; p < 0.0001)
and proximal surfaces (mAPIt2 1.7 ± 0.5; p < 0.0001). Fourteen participants
(7 female, 7 male) were included in phase 3. The PI values in the area of the
smooth and proximal surfaces at time t3b were also significantly lower in
comparison to both t0 and t1. At time t3b, the PI value in the area of the
smooth surfaces did not differ significantly compared to t2 (QHIt2–QHIt3b;
p = 0.147), but the PI value in the area of the proximal surfaces was signifi-
cantly lower (mAPIt2–mAPIt3b; p = 0.024).
Conclusion: The results of this pilot study show that an app or an abacus are
suitable tools for supporting patients to self-monitor their home-based oral
hygiene, which could lead to significantly improved oral health.
Keywords: self-monitoring; self-responsible home-based oral hygiene; CIOTI-
Plus-App; CIOTIPlus-Abacus
Department of Conservative Dentistry, Periodontology and Preventive Dentistry, Hannover: Prof. Dr. Hüsamettin Günay, Dr. Karen Meyer-Wübbold
Translation from German: Christian Miron
Citation: Günay H, Meyer-Wübbold K: Self-monitoring to improve home-based oral hygiene in seniors. Dtsch Zahnärztl Z Int 2021; 3: 111–120
Peer-reviewed article: submitted: 31.03.2020, revised version accepted: 09.07.2020
DOI.org/10.3238/dzz-int.2021.0013
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GÜNAY, MEYER-WÜBBOLD:
112 Self-monitoring to improve home-based oral hygiene in seniors
Introduction “tooth preservation in old age” (sig- tory system is present. The effective-
Caries and periodontitis are biofilm- nificant reduction in tooth loss) is ness of good home-based oral hy-
associated diseases with multifactorial evident [17]. Yet, the more teeth are giene, combined with regular pro-
causes. In addition to regular visits to preserved, the more they are exposed phylactic dental care, for preventing
the dentist and dietary control, the to the risk of disease such as peri- caries and periodontitis has been
efficient removal of oral biofilm plays odontitis or caries. The cause of in- demonstrated in studies [2, 5].
a major role in the prevention of creased susceptibility to root or In order for patients to achieve
these diseases. The removal of biofilm crown margin caries in older people optimal self-responsible home-based
is not only the responsibility of the is multifactorial (e.g. increased pro- oral hygiene results, they should
dental professional, but primarily portion of exposed root surfaces or have the opportunity to indepen-
that of the patient who should carry crown margins, extensive prosthetic dently assess/monitor both their
out regular home-based oral hygiene restorations, inadequate plaque re- cleaning process and result. Many pa-
[5]. Self-responsible home-based oral moval, reduced salivary flow [drug- tients seem to find it difficult to regu-
hygiene is thus an essential com- induced], previous periodontal ther- larly implement a certain system of
ponent for maintaining oral health. apy) [1, 6, 15, 20]. daily dental and oral hygiene. There
The oral health awareness of the Regarding the prevalence of peri- are various possibilities for patients to
German population has increased sig- odontitis, DMS V shows that 75.4 % self-monitor their cleaning process or
nificantly in recent years. In the Fifth of younger seniors suffer from mod- system. In the digital age, apps offer
German Oral Health Study (DMS V), erately severe (every second; 50.8 %) the possibility of assisting patients in
between 70–85 % of the respondents, or severe periodontitis (nearly every performing their daily dental and
depending on age group, were con- fourth; 24.6 %) and 80.6 % of older oral hygiene. However, most of the
vinced that they could contribute seniors (75- to 100-year-olds) from “tooth brushing apps” which are cur-
“very much” or “much” to maintain- moderately severe (every second; rently available on the market can
ing or improving their oral health 50.5 %) or severe periodontitis only be used in combination with a
[17]. Patients therefore appear to be (nearly every third; 30.1 %) [17]. corresponding electric toothbrush
well aware that the removal of However, since the disease increases [16]. The number of apps which can
plaque/biofilm as part of self-respon- with age, the demographic trend sug- be used together with a manual
sible home-based oral hygiene is of gests that the need for treatment is toothbrush is limited and is mainly
great importance in the prevention likely to increase in the future. directed towards children and adoles-
of caries and periodontitis. Especially There is now ample evidence cents [16]. In a qualitative analysis of
in the young senior age group (65 to from epidemiological, clinical and the free apps, which are currently
74 years), a significantly increased experimental studies to suggest that available on the market, and which
awareness of their own oral health periodontal infections are not only are suited for use with manual tooth-
was observed in DMS V [17]. How- influenced by systemic factors, but brushes, 5 “tooth brushing apps”
ever, DMS V also shows that a that they themselves can produce were compared; from the 5 apps,
relatively large number of patients systemic effects [18]. Oral health, only 2 of them were suited for adults
are still affected by caries (especially meaning the unrestricted functional- [16]. The analysis revealed that in all
root and crown margin caries) and ity and freedom from inflammation apps, the implementation of a clear
inflammatory periodontal diseases. and discomfort, is an important com- system of tooth brushing and remind-
Successful prevention concepts, com- ponent of general health and of a er functions promotes regular oral
bined with advances in the field of healthy diet and is thus closely hygiene [16]. The authors concluded
restorative dentistry, have made it linked to quality of life [7, 24]. One that “tooth brushing apps” also have
possible to preserve natural teeth for can only live up to the motto “health the potential to contribute to dental
much longer or even for the entire begins in the mouth” if a well-func- hygiene education for adults, al-
lifespan [19]. A clear trend towards tioning and well-maintained mastica- though most apps provide insuffi-
Figure 1a Front view of the “CIOTIPlus-Abacus” Figure 1b Back view of the “CIOTIPlus-Abacus”
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GÜNAY, MEYER-WÜBBOLD:
Self-monitoring to improve home-based oral hygiene in seniors 113
a) b)
Figure 2a The user can mark the individ-
ual cleaned surfaces/areas by touching
the boxes in the “start oral hygiene” sub-
menu in the CIOTIPlus-App.
Figure 2b Confirmation in the submenu
“start oral hygiene” in the CIOTIPlus-
App. In this submenu, a feedback is given
based on whether the system has been
implemented. Depending on the number
of marked areas, a different smiley ap-
c) pears. The “red smiley” indicates an inad-
equate implementation of the system.
The “yellow smiley” indicates a satisfac-
tory implementation and the “green
smiley” indicates a complete implemen-
tation of the system.
Figure 2c A graphic in the submenu
“overview brushing history” in the CIOTI-
Plus-App illustrates the components of
the “CIOTIPlus” system performed by the
user per day and time of day.
Figure 2d In the submenu “information
about oral hygiene and tools” in the
CIOTIPlus-App, the user has access to
texts and videos which explain the indi-
d) vidual steps of the “CIOTIPlus” system.
cient instructions regarding brushing ning, it is recommended that patients able to show that such protocols
techniques and others contain too implement the “CIOTIPlus” system. work well for short periods of time
many tools which distract users from When using the “CIOTIPlus” tooth when self-monitoring the brushing
the actual purpose of dental and oral brushing system, the sequence of process and can thereby improve oral
hygiene [16]. It should also be con- brushing begins on the chewing sur- hygiene [10]. However, such simple
sidered that apps are not suitable for faces, continues onto the inside sur- protocols are often not very attractive
everyone. Many older people, es- faces and finishes on the outside sur- for the patient in the long term. For
pecially, use newer technical devices faces. This is then followed by the this reason, we have additionally de-
less than younger ones. cleaning of the tongue and the inter- veloped a type of abacus (Fig. 1a and
In order to provide these patients dental spaces. After this procedure, in b). With this tool, the patient has the
with the possibility to self-monitor a separate step, the patients should chance to record the “CIOTIPlus”
their home-based oral hygiene, our systematically brush the already tooth brushing system and technique
working group “oral health care pro- cleaned tooth surfaces and gums daily/weekly in an easy and enter-
motion interdisciplinary” initially de- with an equal pea-sized amount of taining manner. This in turn in-
veloped an “oral hygiene protocol” toothpaste for at least one minute creases the motivation to use this
in which the patients could record using small circular movements tool for the purpose of documenting
the system they had adopted on a (Plus) [10–14]. We evaluated the use and self-monitoring. Unfortunately,
daily basis. Particularly in the eve- of the protocols in a study and were however, no evaluation can be con-
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GÜNAY, MEYER-WÜBBOLD:
114 Self-monitoring to improve home-based oral hygiene in seniors
ducted over a longer period of time been brushed during home-based of the abacus. On the back side, the
which is why we have also developed oral hygiene (chewing surfaces, in- participant can check their daily
an app (Fig. 2a–d). side surfaces, outside surfaces, hygiene routine. At the end of the
As part of a pilot study in cross- tongue, interdental spaces, plus) (Fig. week, the number of wooden beads
over design, it was evaluated if the 2a). When the user started the pro- on the back side presents the parti-
app described above or the “CIOTI- gram, the day and time were regis- cipant with an overview of the sur-
Plus-Abacus” can assist patients in tered by the program. When the faces/areas that may have been
implementing the “CIOTIPlus” tooth program ended, the time (tooth neglected during home-based oral
brushing system and technique dur- brushing time) was also recorded by hygiene. This visual aid is intended
ing self-responsible home-based oral the program. In phase 2, the user to promote discipline.
hygiene. could access additional information
regarding the “CIOTIPlus” tooth Study design and recorded
Methods brushing system. The user now had clinical parameters
The study participants were patients the opportunity to retrieve in- All examinations were performed by
from the recall system (supportive formation regarding the system at a practitioner with the help of an as-
periodontal therapy) belonging to any time in image, text and video sistant. For all participants, the base-
the Department of Conservative Den- form (with sound) (Fig. 2d). line examination (t0) comprised of a
tistry, Periodontology and Preventive Also in this case, the user once general anamnesis, a detailed oral
Dentistry of the Hanover Medical again recorded the tooth surfaces or examination and the recording of the
School. The patients were between 67 areas which were brushed as part of periodontal screening index (PSI).
and 79 years old. their home-based oral hygiene. The The plaque was made visible with
An important exclusion and in- program automatically recorded the the aid of a plaque disclosing agent
clusion criterion for the selection of day, start time and duration (tooth (Mira-2-Ton®, Hager & Werken,
participants was their general state of brushing time) until the point when D-Duisburg). Afterwards, magnifying
health. The following diseases/con- the user finished using the program. glasses (2.5x, Orascoptic, Fa. Sigma
ditions were defined as exclusion Furthermore, after the individual Dental) were used to determine the
criteria: tooth surfaces/areas were recorded modified Quigley-Hein Plaque Index
• severe general diseases, into the program, the program had (QHI) according to Turesky [23] as
• mental or physical disabilities the function of reminding the user well as a modified plaque index
which do not permit cooperation, whether or not particular tooth sur- based on the Quigley-Hein Plaque
• xerostomia, faces/areas were considered. The user Index (modified Proximal Plaque
• patients having exclusively im- then had the possibility to brush Index – mAPI) for the purpose of as-
plant-supported restorations, these missing tooth surfaces/areas and sessing the extent of plaque in the
• heavy smokers. to record them as brushed (Fig. 2b). proximal areas [11]. Before the initial
Furthermore, the participants had to examination, patients were asked
have sufficient remaining teeth (at Description of the to fill out a questionnaire. The ques-
least 20 natural teeth). The patients “CIOTIPlus-Abacus” tions were mainly multiple-choice
were randomly included in the pro- This special abacus was made of and included topics such as “oral hy-
ject if they presented interest upon wood and metal (robust and mois- giene” and “evaluation and assess-
being requested to participate in the ture resistant) (Fig. 1a and b). It con- ment”. After completing the ques-
project. Participation in the project sists of 6 metal arches. Each arch pos- tionnaire, the patients were shown
was voluntary and could be discon- sesses 7 wooden beads which repre- the stained plaque on their teeth sur-
tinued at any time without giving sents a component of the “CIOTI- faces using a magnifying mirror and
reasons. The project received a posi- Plus” system. On the abacus’ base, a mouth mirror. They were again
tive vote from the ethics committee the abbreviations corresponding to asked to appraise their oral hygiene
of the Hannover Medical School the “CIOTIPlus” system were drawn using a questionnaire. In order to cre-
(vote no.: 8512_BO_K_2019). in front of the respective metal arch. ate uniform starting conditions, the
The corresponding 7 wooden beads test persons received a professio-
Description of the have different colors depending on nal tooth cleaning, which included
“CIOTIPlus-App” the component of the “CIOTIPlus” cleaning and polishing of both the
A self-developed app was installed on system. The front side of the vertical smooth and proximal surfaces. The
a tablet PC (Lenova Tab E7 TB-7104F board is marked with the days of the “CIOTIPlus” brushing system was ex-
7“TN Display). The tablet was not week; the back side is marked with plained, demonstrated and practiced.
connected to the Internet. Neither the numbers 1 to 7 and with colored In addition, all participants received
the tablet PC nor the app recorded or lines. Every evening after the partici- an information leaflet which ex-
saved any personal or patient-related pant has finished their oral hygiene plained the system once again in
data (e.g. name, age, gender, date of procedure, the wooden bead cor- image and text. The participants were
birth). The app included 2 phases. In responding to the surface/area which instructed that they should practice
phase 1, the user only could self rec- the participant has brushed is moved implementing the system at least
ord which tooth surfaces/areas had from the front side to the back side once daily during oral hygiene, es-
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GÜNAY, MEYER-WÜBBOLD:
Self-monitoring to improve home-based oral hygiene in seniors 115
pecially in the evening. All patients
received a tablet PC (Lenova Tab E7
TB-7104F 7“TN Display) on which
the self-developed app described
above was installed. With the help of
the app, the patients were expected
to record the systematic procedure as
part of their daily home-based oral
hygiene. The patients were instructed
in how to use the tablet PC and the
program. At this point, the user only
had access to “phase 1” of the pro-
gram. The participant was asked to
record their daily home-based oral
hygiene (noting the cleaned tooth
surfaces/areas) using the app for
3 weeks.
After 3 weeks, re-examination (t1)
was performed. The plaque indices
(QHI and mAPI) were recorded after
the plaque was made visible by stain-
ing and then the teeth (have been)
cleaned. Afterwards, “phase 2” was ac-
tivated on the tablet PC. The partici-
pants were asked to record their daily
practice of home-based oral hygiene
(noting the cleaned tooth surfaces/
areas) for 3 weeks using the “CIOTI-
Plus-App”.
After 3 weeks, a re-examination
(t2) was performed. The plaque in-
dices (QHI and mAPI) were deter-
mined after the plaque was made vis-
ible by staining and then the teeth
were cleaned. Before the examin-
ation, the patients were asked to fill
out a questionnaire which consisted Figure 3 Documentation sheet for phase 3
of multiple-choice questions regard-
ing the tooth brushing system and
the “CIOTIPlus-App”.
After t2, a 6-month break in the
form of a “washout phase” ensued in After these 3 weeks, the last Internet at any time. Neither the tab-
order to avoid a possible “Hawthorne examination (t3b) was performed. let PC nor the “CIOTIPlus-App” rec-
effect” in phase 3 (t3). At time t3a, a Analogous to t1 and t2, the plaque orded or stored any patient-related
re-examination (QHI/mAPI), profes- indices (QHI and mAPI) were rec- data (e.g. name, age, gender, date of
sional tooth cleaning and fluori- orded after plaque staining. Then, birth). A consent form was signed by
dation were performed. The “CIOTI- the teeth were cleaned and fluoride each participant.
Plus” tooth brushing system (+ leaf- was applied. Data analysis was performed with
let) and the use of the “CIOTIPlus- Figure 4 summarizes the project’s the statistical analysis program SPSS/
Abacus” (phase 3) were explained to timeline (flowchart of the project). PC Version 25.0® for Windows (SPSS
the participants. The participants Inc., Chicago, IL, USA). All collected
were asked to record the total Data protection and data was analyzed through pseudo-
number of beads per component of statistical analysis nymization. First, mean values, stan-
the “CIOTIPlus” system at the end of The evaluation performed in this pro- dard deviations and frequencies were
each week in a documentation sheet ject was anonymous. The partici- calculated for the descriptive sta-
(Fig. 3). The participants were once pants were informed that their per- tistics. The collected values arising
again requested to record their home- sonal data would be kept anonymous from repeated measurements within
based oral hygiene in the evening and that it would be exclusively used a group were analyzed for variance
using the “CIOTI Plus-Abacus” for for the purpose of data collection. using the paired T-test. The statistical
3 weeks. The tablet was not connected to the significance level was set at p < 0.05.
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116 Self-monitoring to improve home-based oral hygiene in seniors
(QHIt1–QHIt3b; p < 0.001; mAPIt1–
mAPIt3b; p < 0.001). At time t3b the
plaque index value in the area of the
smooth surfaces did not differ signifi-
cantly compared to time t2 (QHIt2–
QHIt3b; p = 0.147), but the plaque
index value in the area of the proxi-
mal surfaces was significantly lower
mAPIt2–mAPIt3b; p = 0.024) (Fig. 5).
Use of the “CIOTIPlus-App”
and documentation of the
CIOTIPlus-System
The patients were instructed at the
beginning of phase 1 to use the
“CIOTIPlus” tooth brushing system
at least once daily when performing
oral hygiene, especially in the eve-
ning. For this reason, only the use of
the app/documentation of the sys-
tem in the evening was considered in
the following section when analyzing
the results.
On average, the “CIOTIPlus-App”
was used by the participants in the
evening on 24.9 ± 3.3 days in phase 1
and on 18.3 ± 2.5 days in phase 2.
Using the app, the participants
recorded which part of the system
(chewing surface, inside surface, out-
side surface, tongue, interdental
spaces and plus) was performed in
which order. A percentage evaluation
was conducted based on app‘s usage.
The frequency of the parts of the sys-
tem documented by the participant
Figure 4 Flowchart of the project was evaluated. Also, how often the
recommended system was com-
pletely implemented and if it was
performed in the correct sequence
Results and proximal surfaces (mAPIt2 1.7 ± was recorded. It was determined that
0.5; p < 0.0001). The plaque index in phase 2, compared to phase 1, the
Clinical parameters values for the smooth and proximal participants documented the pro-
The study included 16 participants surfaces at time t2 were also signi- portions of the system “tongue”
(8 female, 8 male) with an aver- ficantly lower compared to time t1 (p = 0.037) and “plus” (p = 0.016) sig-
age age of 72.6 ± 4.2 years. In the (QHIt1–QHIt2; p < 0.001; mAPIt1– nificantly more often. In phase 2, ac-
basic examination (t0), the subjects mAPIt2; p = 0.033) (Fig. 5). cording to the documentation pro-
showed an average QHIt0 of 2.1 ± 0.7 In phase 3, 14 participants (7 fe- vided by the participants, all parts of
and an average mAPIt0 of 3.5 ± 0.6. In male, 7 male) remained to be in- the system (p = 0.003) were imple-
the second examination (t1), the par- cluded. At time t3a, the participants mented in the specified order
ticipants showed significantly lower showed an average QHIt3a of 1.9 ± 0.5 (p = 0.016) significantly more fre-
average plaque index values in the and an average mAPIt3a of 2.9 ± 0.7, quently than in phase 1.
area of the smooth (QHIt1 1.6 ± 0.6; while at time t3b, they had an aver-
p = 0.004) and proximal surfaces age QHIt3b of 0.7 ± 0.4 and an average Use of the “CIOTIPlus-Abacus”
(mAPIt1 2.9 ± 0.7; p = 0.003) when mAPIt3b of 1.4 ± 0.6. The plaque and documentation of the
compared to t0. In the third examin- index values on the smooth and CIOTIPlus-System
ation, compared to t0, significantly proximal surfaces at time t3b were At the beginning of phase 3, the pa-
lower average plaque index values also significantly lower than at tients were instructed to apply the
were once again detected on both the times t0 (QHIt0–QHIt3b; p < 0.001; “CIOTIPlus” tooth brushing system at
smooth (QHIt2 0.8 ± 0.4; p < 0.0001) mAPIt0–mAPIt3b; p < 0.001) and t1 least once daily during oral hygiene,
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Self-monitoring to improve home-based oral hygiene in seniors 117
especially in the evening. At the end their dental and oral hygiene on their self-monitor their dental and oral hy-
of a week, the participants were in- own. More than half of the partici- giene at home. When interpreting
structed to read the number of beads pants (57.1 %) would continue to these results, it should be taken into
per component of the system from use the “CIOTIPlus-Abacus” to assist account that apps are not suitable for
the “CIOTIPlus-Abacus” and record it them in their daily oral hygiene. A everyone. Many older people use new
in a documentation sheet (Fig. 3). The large proportion of the respondents technical devices less than younger
documentation sheets were com- (85.7 %) would recommend the aba- ones. The reasons for this are mani-
pletely filled out by all of the partici- cus for self-responsible home-based fold. Firstly, many older people have
pants in phase 3, thus suggesting that oral hygiene. less contact with new technologies
the “CIOTIPlus-Abacus” was indeed The majority of the respondents because they did not grow up with
used by all of the participants during (78.6 %) stated that the “CIOTIPlus- them and often lack an understand-
the entire 3 weeks. Abacus” was easier to use than the ing of how modern technology works
Based on the documentation “CIOTIPlus-App” as a tool for check- [22]. On the other hand, physical
sheets, the frequency as a percentage ing home-based oral hygiene. Addi- challenges that occur with old age,
was calculated for each of the compo- tionally, 64.3 % would also recom- such as visual or hearing impair-
nents of the system which was imple- mend the abacus than the app. ments, limitations in fine motor
mented by the participants. When skills and cognitive limitations can
comparing phase 3 to phase 1, all of Self-control of the cleaning also represent an obstacle [22]. In a
the components of the system were result survey, 41 % of over 1000 people
implemented more frequently by the In the basic examination (t0), it was over the age of 65 stated that they
participants, although this was not found that patients who without vi- had difficulty operating modern
statistically significant. Similarly, all sualization their plaque tended to as- technical equipment [21]. Also, in
components of the system except for sess their oral hygiene as being con- the present study, more than two
the “tongue” were recorded more fre- siderably much better than after vi- thirds of those questioned stated that
quently in phase 3 than in phase 2. sualizing it. Before the plaque was they found it easier to use an abacus
This was, however, again not statis- stained, 6.3 % of patients rated their than an app. An abacus appears to be
tically significant. oral hygiene as being “good” and a suitable tool for getting used to a
93.8 % “very good”. After the stained tooth brushing system. The abacus is
Analysis of the questionnaires plaque and demonstration was re- permanently present and it motivates
All participants (100 %) stated that vealed to them, the patients were or reminds, the patient to implement
they had already performed their very surprised and revised their as- the system in daily dental and oral
daily home-based oral hygiene ac- sessment; 56.3 % of them rated their hygiene. This approach follows the
cording to a certain system before the oral hygiene as “good”, 25 % as “KISS principle”, which stands for
project. All of them (100 %) would “moderate” and 18.8 % as “poor”. “keep it simple and stupid”. This
also like to continue to use the The differences between the assess- means that the easier something is to
“CIOTIPlus” system in the future. ments before and after the demon- understand and use, the more likely
The greater majority of those sur- stration of stained plaque-affected it is that the user or patient will ac-
veyed consider this system to be suit- areas were statistically significant (p = tually use it. The results of the pres-
able for everyday use (93.8 %) and 0.007). The patients’ ability to self-as- ent study support this assumption.
perceive to have a “better mouth feel- sessment plaque after the demonstra- The documentation forms for the
ing” (87.5 %) after brushing accord- tion reflects well the objective find- “CIOTIPlus-Abacus” were completed
ing to this system. All participants ings of the plaque indices. filled out by all participants. There-
(100 %) think that a control mechan- fore, it is reasonable to conclude that
ism for the systematic procedure is Discussion the abacus was also used by all par-
better for the brushing result. In the digital age, apps for the self- ticipants during the entire period of
About two thirds of the respon- management and self-monitoring of investigation. In contrast, the evalu-
dents (68.8 %) stated that the chronic diseases (e.g. diabetes melli- ation of the app showed that it was
“CIOTIPlus-App” was helpful for as- tus) have been successfully used for not used on a daily basis by the par-
sisting them in checking their dental several years [8]. Similar to other ticipants.
and oral hygiene on their own. The areas of general medicine, dental pre- At time t1, the participants used a
majority of participants would con- vention concepts can only be suc- technical device and they recorded
tinue to use the “CIOTIPlus-App” in cessful if compliance, self-responsibil- the performed components of the
the future (87.6 %) and all of them ity and self-monitoring on the pa- system using the “CIOTIPlus-App”.
would recommend the app either tient’s behalf are ensured. However, this was only a pure docu-
generally (81.3 %) or for specific All participants claimed that the mentation procedure which can be
groups of people/special cases abacus helped them to self-monitor compared to oral hygiene protocols.
(18.8 %). their home-based dental and oral hy- This documentation alone already
With respect to the “CIOTIPlus- giene. Only about two thirds of the led to improved home-based dental
Abacus”, all participants (100 %) respondents stated that the “CIOTI- and oral hygiene, which was re-
stated that it helped them to check Plus-App” had supported them to flected in the significantly lower
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118 Self-monitoring to improve home-based oral hygiene in seniors
For the documentation using an
app, the participants had to use a
technical device which can only be
used everywhere to a limited extent.
Such technical devices are sensitive
to moisture and are exposed to the
risk of unintentional destruction, es-
pecially in damp rooms such as bath-
(Fig. 1–5: H. Günay, K. Meyer-Wübbold)
rooms, where daily dental and oral
hygiene is usually performed. This
danger does not exist with an abacus.
Moreover, the documentation using
an app is somewhat more demanding
and takes more time than the docu-
mentation using an abacus. The tech-
nical device had to be started before-
hand and also loaded in the mean-
time. The user was supposed to enter
Figure 5 QHI and mAPI of the participants at times t0, t1, t2, t3a and t3b the individual components of the
system manually in the sequence per-
formed and could also access in-
formation or continue dental and
plaque index values in the area of the smooth and proximal surfaces were oral hygiene after eventually receiv-
smooth and proximal surfaces at again recorded at the beginning of ing instructions. However, the app
time t1 compared to t0. At time t2, phase 3 (t3a) and before using the gave the user the opportunity to pre-
the participants not only recorded “CIOTIPlus-Abacus”. The values de- cisely view the system they had ap-
the components of the system using termined at time t3a clearly show plied on a daily basis; this was pos-
the app, but they also had the oppor- that no “Hawthorne effect” occurred sible retrospectively over a longer
tunity to access information regard- because the values did not differ sig- time consider as well. The “CIOTI-
ing the “CIOTIPlus” tooth brushing nificantly from those determined Plus-App” thus provided precise in-
system and technique in image, text at time t0. formation about which components
and video form (with sound) at any At time t3, the participants used a of the system were implemented in
time via the app. Besides this, the special abacus. The “CIOTIPlus-Aba- which order and when. This control
user received feedback after perform- cus”, unlike an app, is present at all mechanism does not exist when
ing oral hygiene regarding whether times at the place for oral hygiene using an abacus. However, these ad-
tooth surfaces or areas had not been and should serve as a simple visual vantages are unlikely to have played
taken into account. The participants reminder and monitoring mech- a major role for the participants in
then had the opportunity to clean anism. Like at time t1, there was only the present study, at least not for the
these missing tooth surfaces or areas a recording of the implemented com- short 3-week interval of use of the
and record this afterwards. The sig- ponents of the system using the two self-monitoring tools. This is re-
nificantly lower plaque index values “CIOTIPlus-Abacus”. However, the flected both in the clinically collected
in the area of the smooth and proxi- significantly lower plaque index val- plaque index values and in the results
mal surfaces at time t2 compared to ues in the area of the smooth and of the questionnaire.
t0 and t1 suggests that this addi- proximal surfaces at time t3b com- In the basic examination, it was
tional information is helpful for pa- pared to t1 concludes that, with re- found that many patients find it dif-
tients to self-monitor and pursue an gard to the implementation of an ad- ficult to objectively assess their own
adequate home-based dental and oral equate home-based dental and oral cleaning results. A pure visual check,
hygiene. hygiene, the recording using an aba- even with magnifying aids and
Between phases 2 and 3, a longer cus appears to be more helpful than optimal lighting conditions, or a
period (6 months) without further just the documentation alone using “tongue-feel test” to identify any
intervention was deliberately chosen an app, which is simply based on fol- plaque that may still be present, is
in order to avoid a possible “Haw- lowing oral hygiene protocols. The not sufficient and cannot reveal
thorne effect” in phase 3. Due to documentation occurs in a playful hidden “problem” or “weak points”
phases 1 and 2, the participants way when using an abacus, while (e.g. interdental spaces, the inner sur-
could have already been experienced also simultaneously stimulating the faces of the teeth and the areas
in implementing the system, which motor and sensor systems. This around the gum line). We therefore
in turn could have distorted the seems to motivate and also discipline recommend that patients use plaque
results in phase 3. In order to rule the participants more than the mere staining agents (e.g. staining [chew-
out a “Hawthorne effect”, the plaque documentation via the app or oral ing] tablets, rinsing solutions which
index values in the area of the hygiene protocols. stain plaque) to visualize plaque at
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (3)GÜNAY, MEYER-WÜBBOLD:
Self-monitoring to improve home-based oral hygiene in seniors 119
least once a week during their home- problems and weaknesses and thus to made together with the patient as to
based dental and oral hygiene. continuously improve their brushing which self-monitoring option (app,
Plaque staining agents, which can system and technique! protocols, abacus) is appropriate for
make a distinction between “new” Without further intervention, the them and to what extent it is desired.
and “old” plaque are also useful. Pa- success in terms of patient compliance With an app, it is possible to assess
tients should visualize the plaque is likely to be short-term [3, 4]. The re- the results daily, weekly or monthly,
both before starting and after finish- sults of the present study support this and even retrospectively, over much
ing home-based oral hygiene. The assumption. The plaque index values longer timespans. Moreover, the
first staining serves as a guide for per- collected from the participants at time protocols can also be evaluated retro-
forming oral hygiene by allowing pa- t3a differed only marginally from spectively over time. With the aba-
tients to concentrate directly on the those at time t0. Based on the pre- cus, there is only the possibility of a
“problem” or “weak points”. The sec- vious interventions, it would have daily or weekly assessment of the re-
ond staining is then used to check been expected that the participants at sults. The present study could show
the brushing result. A second stain- time t3a were already appropriately that the integration of a self-monitor-
ing after tooth brushing is highly rec- sensitized, which should have led to ing system (e.g. an app or an abacus)
ommended; studies have shown that an improvement/optimization of the into an oral prevention concept is
the plaque staining agent, through home-based dental and oral hygiene, promising. In all oral prevention
the brushing process and the ingredi- and thus, to significantly lower plaque concepts, self-responsibility for oral
ents in the toothpaste (e.g. surfac- index values at time t3a compared to health plays a central role for a sus-
tants), is partially washed out or t0. However, between phase 2 (t2) and tainable/lasting (behavioral) change.
fades, thus making the remaining phase 3 (t3a), there was a 6-month
plaque no longer visible to the pa- period with no further intervention.
tient [10]. A visualization of plaque In the context of self-responsible
helps patients to assess their own oral home-based oral hygiene, a perma- Conflicts of Interest
hygiene. In this study, it was found nent visual reminder with respect to The authors declare that there is no
that patients without visualize plaque the hygiene measures and system to conflict of interest within the mean-
assessed their own oral hygiene as be implemented can potentially moti- ing of the guidelines of the Inter-
being much better than those after vate patients; for example, the con- national Committee of Medical
visualizing it. Before demonstration tinuous presence of the “CIOTIPlus- Journal Editors.
of the stained plaque, 6.3 % of pa- Abacus” or a small poster in the bath-
tients rated their oral hygiene as room/oral hygiene area can serve this
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