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Electric brushes improve outcomes in caregiver-assisted oral hygiene

Vannah, Courtney E. IPDH, MS, MPH; Sammarco, Valia R. RDH

doi: 10.1097/01.NURSE.0000569764.96290.70

Abstract: An effective means of maintaining oral health is imperative for the health of long-term-care patients. This article assesses oral hygiene using an electric toothbrush compared with a manual toothbrush.

The authors conducted a study to compare the merits of caregiver-assisted oral hygiene using electric and manual toothbrushes for plaque control in residents of a long-term-care facility. Read about their findings here.

Courtney E. Vannah is an assistant clinical professor at the University of New England in Portland, Me. Valia R. Sammarco is a student in the Master of Public Health program at Southern New Hampshire University in Manchester, N.H.

The authors have disclosed no financial relationships related to this article.



EFFECTIVE ORAL HYGIENE improves health and helps prevent certain complications for those living in long-term-care (LTC) facilities.1 Although electric toothbrushes have demonstrated advantages in oral care for the overall patient population, they have not been widely used in LTC settings in the authors' experience. This article describes a study conducted by the authors to compare the merits of caregiver-assisted oral hygiene using electric and manual toothbrushes for plaque control in residents of LTC facilities.

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The oral environment is a complex ecosystem in which anaerobic bacteria, facultative aerobes, and spirochetes compete for space and nutrients. Anaerobic bacteria and spirochetes are primarily associated with periodontal disease. Periodontitis is an inflammatory condition that results in the destruction of the periodontium, the supporting structures of the teeth.2

In one study, periodontal disease was linked to such complications as ischemic stroke, carotid atherosclerosis, and decreased glycemic stability in patients with diabetes.2 Patients with periodontal disease are at an increased risk for cardiovascular disease with no known confounders.3

Oral health and diabetes are known for their corresponding relationship. Those with diabetes are at an increased risk for periodontal disease; conversely, those with periodontitis typically have more difficulty managing blood glucose levels, complicating their diabetes.4

Periodontal pockets surrounding the teeth can house a large number of spirochetes and anaerobes. These may increase in size during periods of declining periodontal health. In contrast, an edentulous mouth (lacking teeth) houses comparatively fewer anaerobes, but it may contain more yeast and lactobacilli.5

Poor oral health in either oral environment, whether containing or lacking teeth, can result in various local and systemic disorders, such as local abscess formation, infective endocarditis, and the rapid spread of infection through connective tissue.5 Additionally, oral disease has been linked to various complications, including aspiration pneumonia, osteoporosis, diabetes, stroke, heart disease, rheumatoid arthritis, and other inflammatory conditions.2

For patients at LTC facilities, aspiration pneumonia is a primary concern related to poor oral health. Decreased swallowing and feeding ability; impaired immune status; decreased efficacy of lung defense mechanisms, including poor throat clearance and a weak cough; and declining functional status all place LTC residents at increased risk. Periodontal disease and aspiration pneumonia share the same anaerobic Gram-negative bacteria.2 Patients in facilities that provide adequate oral care have demonstrated a reduced incidence of pneumonia, improving quality of life and reducing facility costs.6

Dental plaque is a contributing factor for periodontal disease. With a growing number of older adults retaining their teeth, rising concerns about maintaining oral health, and increasing awareness that oral and systemic health are closely related, LTC facilities require an effective means of controlling dental plaque.

Since the advent of the electric toothbrush, multiple studies have been conducted that support its efficacy for controlling dental plaque with different populations, but the authors' literature review revealed only a few that were focused on patients in LTC settings.7-9

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Literature review

In a single-blinded, randomized controlled trial on the effectiveness of the electric toothbrush in an LTC facility, 73.3% of participants completed their daily oral hygiene without caregiver assistance.10 While the study researchers did not observe a significant difference in oral health between patients using electric or manual toothbrushes, they did note improved oral health for patients who required caregiver assistance with an electric toothbrush compared with those who used a manual toothbrush. As such, it may be preferred when assistance is necessary, but further research is needed to examine caregiver-assisted oral hygiene with an electric toothbrush given the low percentage of study participants who received assistance.10

Comparing oral health indicators in three test groups, another study demonstrated the role of the nursing staff in maintaining patient oral health in LTC facilities. The groups included those who received periodic oral care performed by a dental hygienist or dental hygiene student at 3-week intervals, those who received daily oral care provided by a trained member of the nursing staff, and those who received neither intervention and performed their own oral care. Daily oral care from a trained member of the nursing staff demonstrated improved oral health indicators in comparison with the other two groups.11

Additionally, two studies demonstrated that caregivers found electric toothbrushes easier to operate and manage than manual brushes.1,12 In one study, caregivers were trained on the operation of electric toothbrushes. Sixty-three percent of participating caregivers reported electric toothbrushes as easier and more efficient in a self-reported survey 15 months later, and 78% were still using them frequently or exclusively.12 This study focused on caregiver perceptions, and the authors recommended further research to determine its effectiveness for plaque control.

In the other study, which focused on ICUs in the US, the nursing staff reported electric toothbrushes as easy to use with a perceived improvement in cleaning.1 The study demonstrated a significant reduction in ventilator-associated pneumonia following the implementation of an oral health protocol that utilized electric brushes.

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Study goals and methods

The authors conducted a study to investigate whether caregiver-assisted oral hygiene with an electric toothbrush results in a significant decrease in plaque scores compared with manual options. The study was reviewed and approved by the Institutional Review Board at the University of New England. Participants were divided into two groups based on the side of the hallway in which they resided. Out of 21 patients at the LTC facility in Maine, 8 patients who were completely dependent on caregivers for oral hygiene were recruited. All participants were age 75 or older. Those who could perform these tasks independently were excluded, as the effectiveness of self-care with electric toothbrushes has been studied extensively.

Study participants were pretested using the plaque index (PLI), a common index in dentistry used to measure the amount of visible plaque on a patient's teeth. It is a valid and reliable means of collecting data that evaluates the teeth for plaque retention. Patients receive a score between 0 and 3 based on the amount of plaque present, with 0 indicating no visible plaque and 3 indicating a large amount of plaque on the tooth and in the natural space between the tooth and surrounding gum tissue (called the sulcus) or at the gingival margin. Scores are then divided by the number of teeth assessed (see PLI score).13

Rather than scoring each tooth individually, dental indices often utilize a subset of the entire dentition in data collection. In this case, the Ramfjord teeth were utilized (see Ramfjord teeth). If one or more of these were missing, the overall score was divided by the total number of utilized teeth. To increase reliability of results, the same experienced registered dental hygienist measured PLI scores at all four data collection points, and group assignments were blinded from the examiner.

Following training on both the electric and manual toothbrushes, the nursing staff used an electric model with Group A and a manual brush with Group B for 8 weeks. Caregivers provided oral care to all hallway residents, unaware of which patients were study participants. After an 8-week period, participant plaque scores were tested again.



Upon completion, the nursing staff returned to their regular oral care operating procedures for 2 weeks to allow patients to return to baseline. After this washout period, a second pretest took place and patient PLI scores were recorded again. The nursing staff was then instructed to use manual toothbrushes with Group A and electric brushes with Group B. After 8 more weeks, the final PLI scores were recorded.

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Data were first analyzed to identify the mean pre- and postintervention PLI scores in both phases, which were compared to determine the difference. The mean differences between the electric and manual methods were compared using the Student's t-test, a statistical analysis used to compare two small, independently collected quantitative data sets.14,15 Electric brushing produced a 20% decrease of 0.59 on a 3-point scale of mean plaque scores; manual brushing produced a 3% increase of 0.08 (see Comparison of PLI scores). A statistically significant difference in plaque scores was seen between the electric toothbrush (mean, -0.59; standard deviation [SD], 0.34) and the manual brush (mean, 0.78; SD, 0.34) (t(15) = -2.9348, P = .011).

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Finding an effective way to manage dental plaque in LTC facilities will lead to improved overall health outcomes for patients. This study supports the hypothesis that electric brushing offers superior outcomes to manual brushing when assistance is required for oral care.10 The use of an electric toothbrush reduced plaque scores in both phases, while manual brushing was associated with an overall increase in plaque scores. Given the reported ease-of-use and nursing staff preferences, along with the improved plaque control demonstrated in this study, the switch to electric brushing may be expected to improve patient well-being.1,12 LTC facilities should consider integrating oral care with an electric toothbrush into their daily routines for patients.

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Student t-tests require random sampling, normality of data distribution, and an adequate sample size. While the crossover in the parallel design allowed for an increased sample size despite a relatively small pool of participants, the total number of observations was still inadequate to meet the required assumptions. The patient pool of 8 produced a sample of only 15 due to the loss of one participant during the second phase, so insufficient data were available. Additionally, a larger sample size would enable the determination of the power of the study and decrease the confidence interval.

Due to the small sample size, all consenting patients were included in the study, which lacked randomization. Further research is recommended to reproduce these results at other hospitals, institutions, and regions to rule out any facility- or region-specific influences that may impact the difference in mean PLI scores between methods.

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After proper training, electric brushing was superior to manual brushing for plaque control in LTC residents when oral hygiene was provided by a caregiver. The clinical implications of this study offer opportunities for LTC facilities to improve existing oral health protocols by integrating electric brushing into their plans of care. Additional research will be necessary to explore the implications of improved oral care on long-term patient health.

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PLI score13

Purpose: Assesses thickness of plaque in the gingival area by evaluating the distal, facial, lingual, and mesial tooth surfaces for plaque retention.

Procedure: Use a periodontal probe to identify plaque levels on each tooth being evaluated.


0. Plaque free

1. Small amount

2. Moderate amount visible to the naked eye

3. Large amount in the sulcus or at the gingival margin

Add scores for all teeth and divide by the number of teeth assessed.

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Ramfjord teeth16

Sigurd P. Ramfjord, a leading researcher and educator in periodontics, selected these six teeth to represent the entire dentition in many epidemiological and clinical investigations.



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electric toothbrush; long-term-care; manual toothbrush; oral care; oral health; oral hygiene; plaque index; PLI; toothbrushing

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