A clinicomicrobiological study to evaluate the efficacy of manual and powered toothbrushes among autistic patients (2024)

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Contemp Clin Dent
v.6(4); Oct-Dec 2015
PMC4678548

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Contemp Clin Dent. 2015 Oct-Dec; 6(4): 500–504.

doi:10.4103/0976-237X.169848

PMCID: PMC4678548

PMID: 26681855

Mayuri Vajawat, P. C. Deepika,¹ Vijay Kumar,² and P. Rajeshwari²

Author information Copyright and License information PMC Disclaimer

Abstract

Aim:

To compare the efficacy of powered toothbrushes in improving gingival health and reducing salivary red complex counts as compared to manual toothbrushes, among autistic individuals.

Materials and Methods:

Forty autistics was selected. Test group received powered toothbrushes, and control group received manual toothbrushes. Plaque index and gingival index were recorded. Unstimulated saliva was collected for analysis of red complex organisms using polymerase chain reaction.

Results:

A statistically significant reduction in the plaque scores was seen over a period of 12 weeks in both the groups (P < 0.001 for tests and P = 0.002 for controls). This reduction was statistically more significant in the test group (P = 0.024). A statistically significant reduction in the gingival scores was seen over a period of 12 weeks in both the groups (P < 0.001 for tests and P = 0.001 for controls). This reduction was statistically more significant in the test group (P = 0.042). No statistically significant reduction in the detection rate of red complex organisms were seen at 4 weeks in both the groups.

Conclusion:

Powered toothbrushes result in a significant overall improvement in gingival health when constant reinforcement of oral hygiene instructions is given.

Introduction

Autism is a disorder of neural development characterized by impaired social interaction and communication, which includes restricted and repetitive behavior.[1] Pervasive developmental disorders (PDDs), commonly referred to as autism spectrum disorders, is an umbrella term for 5 disorders, including: (1) Autistic disorder (AD), (2) Rett's disorder,

(3) childhood disintegrative disorder, (4) Asperger's disorder, and (5) PDD not otherwise specified.[2] Reviews quote a prevalence of 6 per 1000 for autism spectrum disorders as a whole and 1–2 per 1000 for autistics.[3] It has been estimated that there are more than 2 million autistic persons in India. However in India, the majority of people have not been diagnosed for this disorder and do not receive the services they need, as there is a tremendous lack of awareness about autism.[4]

The risk of gingivitis is expected to be higher in children with autism due to improper brushing and flossing, lack of necessary manual dexterity, and the difficulties the caregivers have when brushing their teeth.[5] In addition, generalized gingivitis can be one of the side-effects of medications that are typically prescribed to individuals with autism.[6]

Tooth brushing is the most commonly performed oral hygiene practice in the world. Both powered and manual toothbrushes achieve a high level of oral hygiene, but powered toothbrushes are more efficient, easier to use,[7] and surprisingly appealing to the patients.[8] For these reasons, it has a definite use in some patients lacking fine motor skills, such as handicapped[8] and autistic patients.

The major purpose of tooth brushing is to lower the organisms in dental plaque that are responsible for oral diseases and halitosis. Microorganisms of the red complex (Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola) are the major causative agents in the initiation and progression of periodontal disease. Supragingival plaque removal affects the composition of subgingival microbiota and reduces the counts of these red complex microorganisms.[9] Periodontal pocket bacteria are continuously washed into saliva by gingival crevicular fluid (GCF). Saliva is an easily obtainable and noninvasively collected sample containing microbes which detach from various oral surfaces.[10] Whole saliva is superior to pooled periodontal pocket samples to detect P. gingivalis and T. denticola in the oral cavity.[11] Due to the uncooperative behavior of autistic patients, collection of subgingival plaque samples was anticipated to be difficult. Hence, it was decided to collect saliva samples to detect red complex organisms in these patients.

Autistic patients lack manual dexterity and have poor oral hygiene.[12] Hence, the objective of this study is to compare the efficacy of powered and manual toothbrushes in improving plaque control and gingival health and reducing the salivary red complex microorganism counts in patients with ADs.

Materials and Methods

Study population

This is a single-blind, randomized, controlled, clinical study, conducted between February and May 2012. Ethical approval was obtained from the Ethical Committee of our institution. Individuals with a diagnosis of typical AD were screened for the study from an Autistic Institution.

Selection criteria

Patients diagnosed to have autism in the age group of ≥15 years with a minimum of 20 teeth, with no prior experience of using a powered toothbrush, and willing to participate were selected. Patients were excluded if they had any other systemic disease, were undergoing orthodontic therapy or wearing a dental prosthesis.

Informed consent was obtained from the parents of the selected patients, before commencement of the study. Patients were randomly allotted into two groups by using the lottery method, comprising 20 patients each. The test group received powered toothbrushes, and the control group received manual toothbrushes.

Patients from both groups were instructed to brush their teeth. Demonstration of the brushing technique was given to each patient and his/her caregiver using a model and a toothbrush. The circular Fone's technique was selected as it an easy to learn technique.[13] Patients were sensitized to the powered toothbrushes. They were asked to brush their teeth twice daily for 3 min each time. Caregivers were asked to supervise the patients during tooth brushing for the entire period of the study. Every subject was asked to demonstrate the technique that he/she learned. Individual tailor-made oral hygiene instructions (OHIs) were given to the patient and caretaker at baseline and reinforced at 1 week. The powered toothbrush (Colgate 360° sonic power toothbrush, Colgate-Palmolive Company, 300 Park Avenue, New York City, New York, United States) generated high energy sonic oscillations of 20,000 oscillations per min and in manual toothbrushes (Colgate 360° toothbrush, Colgate-Palmolive Company, 300 Park Avenue, New York City, New york, United States), the number of strokes per min was patient-dependent.

One examiner recorded the clinical parameters using the plaque index (Silness 1964) and gingival index (Loe 1963) at baseline, 1, 4, and 12 weeks. The examiner was blinded from knowing which group the patient was from 2 to 5 ml of unstimulated saliva was collected by the spit method in a sterile container and then transferred to an eppendorf tube. The Saliva was then stored at −80°C. Microbiological analyses of red complex organisms were performed using polymerase chain reaction (PCR) at baseline and at 4 weeks.

Plaque was measured using plaque index; oral hygiene was recorded as excellent when plaque score was 0, good when it was 0.1–0.9, fair when 1.0–1.9, and poor when it was 2.0–3.0. Gingival status was evaluated using gingival index. Gingival score 0.1–1.0 indicates mild gingivitis, 1.1–2.0 indicates moderate gingivitis, and 2.1–3.0 indicates severe gingivitis. A short drug history was taken from the patient. The patients were either on antiepileptics, Indian medicine systems, or without any medication.

Intraexaminer calibration

Intraexaminer calibration was achieved by examination of 10 patients twice, 24 h apart before beginning the study. The Kappa coefficient value for intraexaminer reliability with respect to plaque index scores was 0.79, and gingival index scores was 0.84. These values reflect a high degree of conformity in observations.

Microbiological technique

Nested PCR procedure:[14] DNA Extraction was done from saliva using Qiagen DNA extraction kit. Bacteria-specific primers were used to amplify the 16s rRNA gene using both forward and reverse primers. Table 1 shows the various base pair fragments (bp fragments) and primers used for the particular bacteria. Amplification of each sample was done using a total volume of 20 µl amplification reaction mixture consisting of 0.2 mM deoxynucleoside triphosphate mix, 1.5 mM MgCl₂, ×10 Taq buffer, 1 µM each primer, 1.5 U of Taq polymerase, and 5 µl of template. PCR amplification was performed in a thermal cycler (Eppendorf Pro). PCR cycle for all primer pairs consisted an initial denaturation of 40 cycles at 95°C for 1 min followed by denaturation at 95°C for 30 s, annealing at 65°C for 1 min, and extension at 72°C for 1 min, and then final extension at 72°C for 2 min. Gel photography system (G-BOX) was used as documentation system.[11]

Table 1

bp-fragments and primers used for the particular bacteria

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Statistical analysis

Statistical analysis was done using Statistical Package for the Social Sciences (SPSS): (SPSS Statistics is a software package used for statistical analysis. Long produced by SPSS Inc., it was acquired by IBM in 2009) 20 software. Descriptive statistics, contingency coefficient test, ANOVA test, Chi-square test, and McNemar test were performed. Statistical significance was accepted at a significance level of 0.05. ANOVA was used to compare the mean plaque and gingival scores between the test and control groups. Chi-square test and McNemar test were used to assess the difference between the detection rates of P. gingivalis, T. forsythia, and T. denticola at baseline and 4 weeks.

Results

The mean age in the test group was 18.6 years and in the control group was 17.7 years.

Plaque scores

The baseline, 1-, 4-, and 12-week plaque scores are shown in Table 2. Intragroup analysis in both test (P < 0.001) and control (P = 0.002) groups showed statistically significant reduction in plaque scores over a period of 12 weeks. Intergroup analysis showed a statistically significant reduction in plaque scores in the test group as compared to the control group (P = 0.024). Table 2 shows the mean plaque scores in both groups at various time intervals.

Table 2

Intra- and inter-group comparison of plaque and gingival scores at baseline, 1, 4 and 12 weeks

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Gingival scores

The baseline, 1-, 4-, and 12-week gingival scores are shown in Table 2. Intragroup analysis in both test (P < 0.001) and control (P = 0.001) groups showed a statistically significant reduction in gingival score over a period of 12 weeks. Intergroup analysis showed a statistically significant reduction in gingival scores (P = 0.042). Table 2 shows the mean gingival scores in both groups at various time intervals.

Bacterial load

There was no statistically significant reduction of any of the red complex bacteria in both the intragroup and intergroup analyses. Table 3 shows the detection rate of various microorganisms at different time intervals.

Table 3

The detection rate of P. gingivalis, T. forsythia and T. denticola at baseline and 4 weeks using Chi-square and McNemar test

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Discussion

The purpose of the present study was to assess and compare the effects of manual and powered tooth brushing in young adults with autism spectrum disorders both clinically and microbiologically after reinforcement of adequate OHI. Forty individuals with autism spectrum disorder were selected from an autistic institution and randomly allocated into 2 groups; test group received powered toothbrushes, and the control group received manual toothbrushes.

Powered toothbrushes, which were introduced in the 1960s, as an alternative to manual toothbrushes are known to be beneficial in patients with special needs.[15] In a study of autistic population in India, it was found that autistic patients frequently needed assistance in brushing had a higher rate of periodontal disease and lower caries compared to controls.[16] Thus, the primary outcome of this study was to achieve lower plaque and gingival scores in autistic patients. The secondary outcome was to reduce the bacterial count of salivary red complex microorganisms.

Good compliance was seen in both groups. The baseline plaque and gingival scores could not be made zero, as performing supra-gingival scaling in the autistic institution was not possible. However, at baseline, there was no significant difference in the mean plaque and gingival scores between the tests and controls as shown in Table 2.

Autistic patients are frequently prescribed with medications, which may have an influence on the periodontal status.[6] A short drug history was taken from the patient. In the present study, there was no significant difference in the medication history between the test and control groups.

The reduction in plaque and gingival scores in both and between groups can be attributed to the constant reinforcement of OHI given to the subjects and supervision by the caregivers. The significant improvement in the test group can be attributed to the ease of using powered toothbrushes with lesser effort. In addition, the numbers of oscillations in the powered toothbrushes are predetermined, whereas, in the manual toothbrushes, the number of strokes is dependent on patient's dexterity. The powered toothbrush has proven to play a major role in enhancing patient compliance and motivation.[17,18]

This is in accordance with previous studies which have found a statistically significant reduction in the clinical parameters in powered toothbrushes as compared to manual toothbrushes. Few studies have contradicted this stating that powered toothbrushes were not superior to manual toothbrushes in improving gingival health.[17,19,20,21] However; many of these studies[17,19,20] have been conducted on a normal population whereas the present study was conducted on a special need population.

PCR methods have been proven valuable for the detection of periodontopathic bacteria in periodontal pocket samples.[22,23] However, as the microbiota may vary significantly from periodontal pocket to periodontal pocket within a subject, a large number of pockets may have to be examined to confirm or exclude the oral presence of specific periodontopathic species. Given that periodontal pocket bacteria are continuously washed into saliva by GCF, a whole saliva sample may offer a rapid and easy alternative to individual pocket samples for determining subgingival bacterial presence. Saliva represents an easily and noninvasively obtainable sample containing bacteria from all oral sites, Umeda et al.[11] showed that whole saliva is superior to pooled periodontal pocket samples to detect P. gingivalis, T. forsythia, and T. denticola. Saliva is easily obtainable from the oral cavities of young autistic children than subgingival plaque. Thus, saliva was used in the present study to detect the periodontal pathogens.

There was no statistically significant reduction in the red complex organisms in both groups. Haffajee et al. 2001[9] have found that supragingival plaque removal decreases counts and prevalence of periodontal pathogens in both the manual and powered toothbrush groups. In the present study, as scaling was not done prior to the initiation of the study, a significant reduction in the bacterial load might not be expected. In addition, the nested PCR technique is highly sensitive as compared to the other culture techniques and it does not provide a quantitative assessment of the bacterial counts such as the real-time PCR technique. Hence, these could explain the reasons for the insignificant results obtained.

The study examines the efficacy of manual and powered toothbrushes among a large population of autistic patients. The study has been complemented by the detection of red complex organisms using PCR. The limitation of this study is that the subgingival plaque for microbial analysis could not be obtained due to apprehensive behavior of the autistic patients. Furthermore, a quantitative PCR could not be carried due to lack of resources.

Oral health is integral to general health and quality of life. Basic oral health services are an essential component of primary healthcare. To the best of our knowledge, this is the first interventional study done on this population. This study adds to literature the importance of special preventive measures to improve their oral health. Attempts should be made by parents and dentists to teach oral hygiene methods to these patients by constant repetition and patience, as autistic individuals can develop skills over a period of time.

Conclusion

In patients with autism spectrum disorder, powered toothbrushes result in a significant overall improvement in plaque control and gingival health, when constant reinforcement of OHI is given. However, there was no difference in the detection rate of red complex organisms between the groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Barbaresi WJ, Katusic SK, Voigt RG. Autism: A review of the state of the science for pediatric primary health care clinicians. Arch Pediatr Adolesc Med. 2006;160:1167–75. [PubMed] [Google Scholar]

2. Volkmar FR, Reichow B, McPartland J. Classification of autism and related conditions: Progress, challenges, and opportunities. Dialogues Clin Neurosci. 2012;14:229–37. [PMC free article] [PubMed] [Google Scholar]

3. Newschaffer CJ, Croen LA, Daniels J, Giarelli E, Grether JK, Levy SE, et al. The epidemiology of autism spectrum disorders. Annu Rev Public Health. 2007;28:235–58. [PubMed] [Google Scholar]

4. [Last accessed on 2014 Dec 13]. Available from: http://www.autism.india.org/afa_autisminindia.html .

5. Jaber MA, Sayyab M, Abu Fanas SH. Oral health status and dental needs of autistic children and young adults. J Investig Clin Dent. 2011;2:57–62. [PubMed] [Google Scholar]

6. Friedlander AH, Yagiela JA, Paterno VI, Mahler ME. The neuropathology, medical management and dental implications of autism. J Am Dent Assoc. 2003;31:681–91. [PubMed] [Google Scholar]

7. van der Weijden F, Echeverria JJ, Sanz M, Lindhe J. Mechanical supragingival plaque control. In: Lindhe J, editor. Clinical Periodontology and Implant Dentistry. 5th ed. United Kingdom: Blackwell Publishing Ltd; 2008. p. 724. [Google Scholar]

8. Aruna K, Rosaiah K, Muktishree M. Comparative evaluation of clinical efficacy of manual and powered tooth brush. Indian J Stomatol. 2011;2:233–7. [Google Scholar]

9. Haffajee AD, Smith C, Torresyap G, Thompson M, Guerrero D, Socransky SS. Efficacy of manual and powered toothbrushes (II). Effect on microbiological parameters. J Clin Periodontol. 2001;28:947–54. [PubMed] [Google Scholar]

10. Könönen E, Paju S, puss*nen PJ, Hyvönen M, Di Tella P, Suominen-Taipale L, et al. Population-based study of salivary carriage of periodontal pathogens in adults. J Clin Microbiol. 2007;45:2446–51. [PMC free article] [PubMed] [Google Scholar]

11. Umeda M, Contreras A, Chen C, Bakker I, Slots J. The utility of whole saliva to detect the oral presence of periodontopathic bacteria. J Periodontol. 1998;69:828–33. [PubMed] [Google Scholar]

12. Luppanap*rnlarp S, Leelataweewud P, Putongkam P, Ketanont S. Periodontal status and orthodontic treatment need of autistic children. World J Orthod. 2010;11:256–61. [PubMed] [Google Scholar]

13. Ainamo J, Xie Q, Ainamo A, Kallio P. Assessment of the effect of an oscillating/rotating electric toothbrush on oral health. A 12-month longitudinal study. J Clin Periodontol. 1997;24:28–33. [PubMed] [Google Scholar]

14. Byrne SJ, Dashper SG, Darby IB, Adams GG, Hoffmann B, Reynolds EC. Progression of chronic periodontitis can be predicted by the levels of Porphyromonas gingivalis and Treponema denticola in subgingival plaque. Oral Microbiol Immunol. 2009;24:469–77. [PubMed] [Google Scholar]

15. Weijden van der GA, Timmerman MF, Danser MM, van der Velden U. The Role of Electric Toothbrushes: Advantages and Limitations. Proceedings of the European Workshop on Mechanical Plaque Control. 1998:138–55. [Google Scholar]

16. Vajawat M, Deepika PC. Comparative evaluation of oral hygiene practices and oral health status in autistic and normal individuals. J Int Soc Prev Community Dent. 2012;2:58–63. [PMC free article] [PubMed] [Google Scholar]

17. Hoover JN, Singer D. Toothbrushes: Manual and electric. J Can Dent Assoc. 1994;60:880–4. [PubMed] [Google Scholar]

18. Hafajee AD, Smith C, Torresyap G, Thompson M, Guerrero D, Socransky SS. Efficacy of manual and powered toothbrushes (II). Effects on clinical parameters. J Clin Periodontol. 2001;28:937–46. [PubMed] [Google Scholar]

19. Forgas-Brockmann LB, Carter-Hanson C, Killoy WJ. The effects of an ultrasonic toothbrush on plaque accumulation and gingival inflammation. J Clin Periodontol. 1998;25:375–9. [PubMed] [Google Scholar]

20. McCracken GI, Heasman L, Stacey F, Steen N, DeJager M, Heasman PA. A clinical comparison of an oscillating/rotating powered toothbrush and a manual toothbrush in patients with chronic periodontitis. J Clin Periodontol. 2004;31:805–12. [PubMed] [Google Scholar]

21. Goyal S, Thomas BS, Bhat KM, Bhat GS. Manual toothbrushing reinforced with audiovisual instruction versus powered toothbrushing among institutionalized mentally challenged subjects – A randomized cross-over clinical trial. Med Oral Patol Oral Cir Bucal. 2011;16:e359–64. [PubMed] [Google Scholar]

22. Chen C, Ashimoto A, Sangsurasak S, Flynn MJ, Slots J. Oral food consumption and subgingival microorganisms: Subgingival microbiota of gastrostomy tube-fed children and healthy controls. J Periodontol. 1997;68:1163–8. [PubMed] [Google Scholar]

23. Watanabe K, Frommel TO. Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Treponema denticola detection in oral plaque samples using the polymerase chain reaction. J Clin Periodontol. 1996;23(3 Pt 1):212–9. [PubMed] [Google Scholar]

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