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I S S U E S A N D IN N O V A T I O N S IN N U R S I N G P R A C T I C E

A controlled trial to compare the ability of foam swabs and


toothbrushes to remove dental plaque
Linda Susan Pearson BSc RGN PhD PGCE(FE)
Distance Learning Facilitator, Royal College of Nursing Institute, formerly Lecturer in Nursing Studies, School of Nursing,
University of Hull, Hull, UK

and Jane Luise Hutton BSc DipMathStat PhD DIC CStat


Senior Lecturer in Medical Statistics, Department of Statistics, University of Warwick, Coventry, UK

Submitted for publication 13 July 2001


Accepted for publication 31 May 2002

Correspondence: P E A R S O N L .S . & H U T T O N J .L . ( 2 0 0 2 ) Journal of Advanced Nursing 39(5),


Linda Pearson, 480–489
2 Westbourne Grove, A controlled trial to compare the ability of foam swabs and toothbrushes to remove
Selby,
dental plaque
North Yorkshire YO8 9DG,
Aims of the study. To measure how effective foam swabs are at removing dental
UK.
E-mail: lp2work@aol.com plaque when compared with using a toothbrush and to quantify any difference in
ability.
Background. Few nursing studies have aimed to determine the effectiveness of
different mouth care tools to remove plaque which is associated with the tooth/
gingival margin and, therefore, with gingivitis and chronic inflammatory perio-
dontal disease. Findings from a previous case study of two people that compared the
ability of foam swabs and toothbrushes to remove plaque at the gum/tooth margin
(gingival crevice) and plaque from between teeth (approximal plaque) suggested that
the success of a toothbrush is affected by user technique and that foam swabs are not
able to remove plaque from some sheltered areas of teeth.
Methods. A time-series, cross-over controlled trial with 34 volunteers was used to
determine the ability of foam swabs and toothbrushes to remove dental plaque
which had been allowed to accumulate overnight. Plaque accumulations were
scored at each approximal and crevice site for the buccal surfaces of the eight upper
and eight lower teeth after each treatment of either toothbrushing or swabbing.
Results. Plaque frequency distributions in the form of boxplots, together with
results from summary statistics demonstrate that toothbrushes performed substan-
tially better than foam swabs in the ability to remove plaque from the sites studied in
this larger sample of people.
Conclusions. The trial verified the findings from the previous study. The conclu-
sions can be generalized to a wider population because of the magnitude and
direction of the differences measured. The implications for nurse education and the
development of nursing in practice settings include the need to teach effective
toothbrushing skills to nurses, and to support clinical staff in developing mouthcare
practice, particularly in relation to the use of assessment strategies that include the
choice of effective tools.

Keywords: clinical trial, dental plaque removal, mouthcare tools, effective nursing
practice

480  2002 Blackwell Science Ltd


Issues and innovations in nursing practice Plaque removal capability of mouthcare tools

importance of plaque that accumulates along and below the


Introduction
gingival margin (Levine 1989) and so it is important
Mouthcare is a concept familiar to nurses and is a term used that future studies quantify this plaque. Plaque allowed to
to embrace the care given in a variety of situations that accumulate in this area is reported to cause tissue changes
require decisions to be made about what tools and actions are within 2–4 days (Page & Schroeder 1976) and will result in
likely to achieve the best outcome for patients or clients with clinically apparent gingivitis within 7–21 days (Löe et al.
the minimum of risk (Trenter Roth & Creason 1986, 1965, Theilade et al. 1966).
Griffiths & Boyle 1993, Kite & Pearson 1995, Pearson & Toothbrushing is a very common means of plaque removal
Chin 1997). One tool commonly employed in mouthcare is in Western populations, although it is not always effective
the foam swab. and can result in problems if not used correctly (Addy et al.
Foam swabs have been used in the United Kingdom (UK) 1992). The effect of different kinds of toothbrush on plaque
since the early 1970s, and, despite repeated and long-standing removal and gingival health is an ongoing focus in dental
efforts to improve the practice of mouthcare given by nurses research where clinical trials to compare the effect of different
(e.g. DeWalt & Haines 1969, Wiley 1969, DeWalt 1975, tools on a variety of oral indices are common (Bastiaan 1984,
Howarth 1975, 1977, Harris 1980, Lewis 1984, Trenter 1986, Gibson et al. 1986, Killoy et al. 1989, Agerholm
Roth & Creason 1986, Hunt 1987, Miller & Rubinstein 1991).
1987, Pritchard & Mallet 1992, Clarke 1993), they are An earlier series of experiments completed in the mouths of
frequently used in practice today. This may be in part due to a two people to compare the effect of a toothbrush and foam
lack of robust information about what it is that foam swabs swabs on plaque accumulation and removal (Pearson 1996)
can bring to quality nursing practice, and to the lack of have suggested that toothbrushes could remove plaque from
emphasis in education and practice on the assessment of the sites studied if used effectively and that foam swabs
mouthcare needs, and delivery of effective care (Adams could not remove plaque which had accumulated in shel-
1996). tered areas on or between teeth. These findings could inform
The evidence-based practice movement of the 1990s decision-making by educators with a responsibility for skill
(Kitson 1997) and current emphasis on the need to identify development and clinical practice if they were found to be
and use effective interventions in health care in the UK generalisable to a wider population, i.e. effective toothbrush-
requires that we look more carefully at what we do, and ing skills would enhance care, and foam swabs would not be
for evidence to support decision-making wherever possible a tool of choice when care aimed to remove dental plaque.
(Closs 1997). Although mouthcare is a complex concept This paper is a report of a clinical trial, which sought to
which uses knowledge from a variety of sources (Carper measure how effective foam swabs are at removing dental
1978), it does use empirical or scientific knowledge that can plaque, when compared with a toothbrush.
and should be collected systematically. This knowledge can
then underpin and inform decisions made in the context of
The study
planning and delivering care.
Evidence for the ability of foam swabs to clean tooth
Research questions
surfaces by removing dental plaque from tooth surfaces is
limited. Studies that seek such evidence need to use methods The research questions addressed by the study are:
that make plaque visible to the naked eye, and to quantify the • Is there a difference between the ability of foam swabs and
amount of plaque visible. These factors make practice-based a toothbrush to remove dental plaque from approximal
studies difficult and potentially unethical, and may have and crevice surfaces?
contributed to the lack of robust studies in the area. One And, if there is a difference,
study frequently quoted as evidence for foam swabs being • What is the magnitude of the difference between the ability
ineffective at removing plaque is that of DeWalt (1975). Here of foam swabs and a toothbrush to remove dental plaque
plaque accumulations were quantified on volunteers using from approximal and crevice surfaces?
the scoring procedure of Greene and Vermillion (1960). The
amount of plaque on tooth surfaces was estimated after using
Method
a plaque disclosing solution and was recorded as the area of
each tooth covered. The method used to report this trial was guided by the
More recent findings relating to the role of plaque in the proposals of The Standards of Reporting Trials Group
onset and progression of gingivitis in humans highlight the (1994). Oakley (1990) describes the origins and limitations

 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489 481
L.S. Pearson and J.L. Hutton

of the randomized control trial as a means of generating did not have their upper and lower eight front teeth were
information for use in situations where people are the focus excluded from the study. Those who had dental caps on teeth
of the trial. This study uses the method as a means for were advised that the plaque disclosing tablets (Boots Com-
generating information that can then be applied carefully to pany Limited, Nottingham, UK) might initially leave a residual
the practice situation. stain on these teeth and that this stain would fade after
successive cleaning of the teeth. The decision regarding
Preparation for the study whether to be included in the study was then left to individuals.
The plaque scoring system used previously (Pearson 1996)
and described in Fig. 1 was used to quantify plaque that had
Protocol
accumulated along the gingival crevice and approximal
buccal surfaces (see Figure 3) of the upper and lower four The protocol used for the study is given in Fig. 2. Thirty-four
teeth either side of the mid-line. These surfaces were chosen volunteers (mainly staff and students) took part in the
because they are easily accessible to the tools used in the trial, which involved attending two 30-minute appointments
trial, i.e. a toothbrush and foam swab, and easily seen by 1 week apart (Week one – Appointment 1, and Week 2 –
the scorer. Therefore they represent what might be consid- Appointment 2 in Fig. 2). Participants refrained from their
ered the best performance areas for both tools. Measure- usual toothbrushing practice on the morning of each
ment of plaque was practised by the scorer, and accuracy of appointment and had the plaque on the buccal surface of
recording checked through the process of two researchers the upper and lower front eight teeth (four either side of the
comparing scores for disclosed plaque collections on buccal midline) disclosed and scored. This score represented the
surfaces of teeth in photographs and on each others teeth. Baseline before treatment scores in Fig. 2. The plaque scorer
wore a fresh disposable latex rubber glove on the hand used
Ethical approval and recruitment of participants to uncover the teeth under investigation during the plaque
Issues relating to the study design and purpose, methods of scoring procedure. This procedure took place in the same
recruitment and feedback to participants, and data collection geographical location throughout the study and used natural
methods were all subjected to the scrutiny of a departmental light supplemented with light from a reading lamp if the
ethics committee, which then gave approval for the work to former was not adequate.
proceed. Participants were then allocated to one of two groups
Volunteers were recruited to the study through a depart- (Group A & Group B) using alternate allocation in order to
mental open seminar which addressed the scientific basis for ensure that group sizes were kept the same. Randomization
nurse-administered mouthcare; personal invitation; respond- of individuals was not essential because each person acted as
ing to a call for participants via departmental notice boards; their own control. Each group then proceeded through its
and by personal referral after talking to people who had own order of treatments, which were reversed in the second
already taken part in the study. Preliminary findings of the week. This reversal of the order of treatments was included in
study were reported back to participants. the design of the study to ensure that any learning effect
The nature of, and need for, such a study was explained to resulting from the order of treatments (toothbrushing or
all potential participants prior to being recruited. People who using foam swabs) could be assessed.

Figure 1 Plaque scoring system.

482  2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Issues and innovations in nursing practice Plaque removal capability of mouthcare tools

Figure 2 Protocol used for study.

In week 1, Group A people used a toothbrush first, had pants were asked to clean their teeth using their normal
their plaque scored, and then used a foam swab before having toothbrushing procedure but without using a mirror. When
their plaque scored again (final score for week 1). In week 2 using a swab, they were instructed to use a swabbing tech-
these people used a foam swab first, had their plaque scored, nique, i.e. to moisten the swab with tap water and to wipe
and then used a toothbrush before having their plaque scored it horizontally across all the teeth in the experimental area
for a final time (final score for week 2). in both directions, concentrating the action on the tooth-
In week 1 Group B people used a foam swab as the first gingival margin under investigation. This was to mimic the
treatment, had their plaque scored, and then used a toothbrush attention that the sites under investigation might receive
before having their plaque scored again (final plaque score for during mouthcare in a clinical situation.
week 1). In week 2 these people used a toothbrush first, had
their plaque scored, and then used a foam swab before having Data collection
their plaque scored for the final time (final score for week 2). Data were recorded for plaque in the gingival crevice and
Participants were given feedback about any residual plaque approximal sites (Fig. 3) for each of the eight upper and eight
at the end of the scoring procedure in week 2 and methods lower teeth under investigation in each person at each stage
which might ensure total plaque removal during their normal of the study. Each tooth has two approximal surfaces and
toothbrushing procedure. Further referral for advice about one crevice surface. The total number of plaque accumula-
aspects of mouth care were offered and discussions of issues tion sites studied was 1632, made up of 816 upper and 816
which had been highlighted by the study occurred in groups lower sites, of which 1088 were approximal and 544 were
and in one-to-one settings. crevice sites.
Data were entered into the MINITAB statistical analysis
Treatments package in a form that enabled the research questions to be
Toothbrushes were supplied by Johnson and Johnson Patient addressed.
Care Limited, Ascot, UK. When using a toothbrush, partici-

 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489 483
L.S. Pearson and J.L. Hutton

Teeth from above

Smooth surface Approximal Fissure


plaque plaque plaque

Teeth from the side

Supra-gingival
plaque

Sub-gingival
plaque
Gum margin Gingival crevice Figure 3 Plaque accumulation sites (taken
plaque from Pearson 1996).

effect from week 1 to week 2. This was achieved by seeing if


Results
there was any significant difference between the sets of data
The study was designed to assess whether there is a difference outlined above at the beginning of each experiment, and after
between the ability of a foam swab and a toothbrush to similar treatments across the weeks.
remove dental plaque from surfaces of the teeth; from Analysis of variance of the baseline data showed that there
different surfaces of teeth (viz approximal and crevice); and was no significant difference (P > 0Æ2) between plaque
from different places in the mouth (viz upper vs. lower and scores for individuals and groups for weeks one and two
left vs. right). A further aim was to quantify any differences (see Table 1). This was the case for total plaque scores, upper
found. and lower plaque scores, left and right sides, approximal and
Descriptive statistics, contingency tables, analysis of vari- crevice plaque scores. Therefore there was no statistically
ance (ANOVA ) and paired t-tests were used to analyse the data significant difference between groups A and B baseline data
after checking the distribution of the scores. Non-significant and no measurable effect of the individuals being in the trial.
higher order interactions were eliminated before the main In addition, there was no significant difference (P > 0Æ2)
effects of treatments were assessed. Although the initial between the final data (plaque scores after treatment 2) and
plaque scores were ordinal, the significance tests used data produced as a result of the order of the treatments
were based on the normal distribution. The scores used in between the groups and weeks (toothbrushing or swabbing
the statistical tests were average scores for each person, for as a first treatment, regardless of which week it occurred in).
example over 32 sites for approximal surfaces or 16 sites Analysis of variance of the differences between scores after
for crevice surfaces. The legitimacy of the use of the normal swabbing and after brushing indicated no difference
distribution was confirmed by histograms of these mean between upper and lower, or left and right sides. These
plaque scores: this was as expected from the central factors can therefore be eliminated by taking their averages
limit theorem (Armitage 1971). No significant difference is over them.
used when P > 0Æ2 (not even marginal evidence for these
differences).
Summary statistics
In order for the research questions to be answered it was
important to ensure that the baseline data for weeks 1 and 2 The consequences of the similarities in baseline and final data
(starting plaque scores) were similar (not statistically differ- for the two groups and weeks means that we can be confident
ent) and that there had been no carry over/historical learning the changes in plaque scores after treatments are best

484  2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Issues and innovations in nursing practice Plaque removal capability of mouthcare tools

Table 1 Summary statistics for order of treatment and for crevice and approximal plaque accumulation

Mean SD Minimum Maximum


Site C ¼ crevice,
A ¼ approximal C A C A C A C A

Baseline 1Æ07 1Æ27 0Æ35 0Æ18 0Æ0 1Æ0 1Æ80 1Æ81


Treatment 1 ¼ brush 0Æ08 0Æ33 0Æ13 0Æ23 0Æ0 0Æ0 0Æ5 0Æ88
Treatment 2 ¼ swab 0Æ03 0Æ28 0Æ07 0Æ21 0Æ0 0Æ0 0Æ3 0Æ66

Baseline 1Æ16 1Æ31 0Æ33 0Æ24 0Æ13 1Æ0 1Æ88 1Æ88


Treatment 1 ¼ swab 0Æ61 1Æ15 0Æ30 0Æ17 0Æ0 0Æ88 1Æ31 1Æ75
Treatment 2 ¼ brush 0Æ02 0Æ31 0Æ06 0Æ21 0Æ0 0Æ0 0Æ31 0Æ78

demonstrated visually with the use of box plots (see Figs 4 the toothbrush consistently removed more plaque than
and 5) alongside a summary of the statistics given in Table 1. swabs.
Boxplots are a useful visual tool to assess how data are distri- When toothbrushing is the first treatment (point 2 on the
buted (Donnan 1996) and use the concept of quartiles, i.e. the x-axis scales of Figures 4 and 5) approximal sites scores move
three points that divide data into quarters. The box ends from a baseline mean of 1Æ27 to 0Æ33. In contrast, when
mark the upper and lower quartiles, i.e. the points at which swabbing is the first treatment (point 5 on the x-axis scales of
25% of the data occur above and below. The line that divides Figures 4 and 5) the scores move from a baseline mean of
each box represents the middle quartile, i.e. the median. 1Æ31 to 1Æ15 (Table 1). These means indicate that there are
Unusual values or outliers are shown with an asterix. more approximal sites left with more plaque on them after
The boxplots plot the mean plaque scores for each swabbing than there are after brushing. A similar pattern is
individual against the different stages/treatments in the seen when summary statistics and boxplots for crevice sites
study for the crevice sites (Figure 4) and approximal sites are examined, although the final mean scores are lower,
(Figure 5). In each instance the effect of swabbing reduces reflecting the greater accessibility of crevice sites to both
the previous plaque score only slightly, in contrast to toothbrushes and swabs.
toothbrushing, which reduces the previous score more The differences in the magnitude of shifts in plaque scores
dramatically. The analysis of the difference between the after the two treatments can also be seen by examining the
effect of toothbrush and swab on plaque scores shows that example of raw data (Figure 6).

6
Stage measurement taken

0 1 2

Mean plaque score


Figure 4 Boxplots of mean scores on 1 – Before; 2 – After brush first; 3 – After swab second
crevice surfaces by treatments. 4 – Before; 5 – After swab first; 6 – After brush second

 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489 485
L.S. Pearson and J.L. Hutton

5
Stage measurement taken

0 1 2

Mean plaque score


1 – Before; 2 – After brush first; 3 – After swab second; Figure 5 Boxplots of mean scores on
4 – Before; 5 – After swab first; 6 – After brush second. approximal surfaces by treatments.

Table 2 demonstrates the difference in effectiveness majority of plaque that was present on teeth in this study
between toothbrushing and swabbing for crevice and was relatively new and nonadherent because most of it was
approximal sites. The average mean score for approximal removeable by using a toothbrush properly. However, the
sites with a toothbrush is 0Æ77 less than the mean score after nature of the baseline data may not be the same if it were
using a swab (P ¼ 0Æ001). This means, approximately, that ethical to repeat the study with an actual patient/client
there are 77% more clean approximal sites after using a group. Initial plaque levels may well be higher in some
toothbrush than there are after using a swab. groups and in some people there may be accumulations of
The average mean score for crevice sites with a toothbrush mature plaque calcified on tooth surfaces which are not
is 0Æ44 less than the mean score after using a swab (P ¼ removable with foam swabs or toothbrushes. Certainly the
0Æ001). This means, approximately, that there are 44% impact of using foam swabs on such plaque would be
more clean crevice sites after using a toothbrush than there minimal, less than on newer plaque, and less than if a
are after using a swab. toothbrush were used.
The tooth surfaces chosen in this study represented those
that are easily seen and scored for plaque, and which are most
Discussion
accessible to either of the tools. As such they almost represent
a laboratory setting where the tools are given the best chance
Critique of the study design
of working, and where errors in scoring of plaque are
The consequences of the similarities throughout the data set minimized. The plaque removing capabilities of the tools in
described above means that there were no problems with different areas of the mouth may vary, but again, toothbru-
using alternative allocation of participants to groups. Ran- shes will perform better than swabs.
dom allocation would have been preferable. Alternative In this study the mouthcare was delivered by each person
allocation was more convenient, and the lack of period themselves, and the effect of this could well be different than
and carry-over effects shows that it is effective for this if the care was delivered by someone else, for example, a
evaluation. nurse delivering mouthcare. The direction of the difference
The direction of differences between the effectiveness of would depend on a number of factors, e.g. the dexterity of the
swabs and toothbrushes uncovered in this trial is unlikely to person doing the mouthcare (self or other), the accessibility of
be different after replication with a sample from a similar the tooth surfaces. Pooling of the plaque score data for
population group, or if the sample size were increased. The analysis purposes means that the range of effects of the tools

486  2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Issues and innovations in nursing practice Plaque removal capability of mouthcare tools

Figure 6 Example of a completed data collection tool.

on plaque in the mouths of individual cases is lost. This


Application to nursing practice
emphasizes the importance of feedback to individuals who
took part in the study. The results of this trial need careful application to nursing
Finally, the actual techniques for swabbing and tooth- practice. Choice of mouthcare tools takes place within
brushing were only partially standardized. However, the the complexities of care. Local issues known to individual
magnitude and direction of the differences in the performance practitioners and patients/clients need consideration and risk
of the two tools is such that this is very unlikely to have had a assessment where appropriate. These might include patient
significant effect on the performance of each. preference and informed choice, the aims of each mouthcare

 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489 487
L.S. Pearson and J.L. Hutton

Table 2 Demonstrating the difference in effectiveness between Studies in Hull University) who administered the trial and
toothbrush and swab for crevice and approximal sites collected plaque accumulation data, and to Johnson and
Means for mean scores by Johnson Patient Care Limited, Ascot, for supplying us with
crevice and approximal sites toothbrushes for the trial.

Crevice Approximal

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