https://doi.org/10.53453/ms.2023.3.5
Patients’ oral health behaviour modifying mobile application
development and research protocol for its usability assessment
Jurgita Andruškienė
1
, Evelina Daugėlienė
1
, Šarūnė Barsevičienė
1
, Viktorija Venevičienė
1
, Arnas
Murauskas
1
1
Klaipeda State University of Applied Sciences, Department of Oral Care, Klaipeda, Lithuania
Abstract
Background. There is a lack of mobile applications monitoring the periodontal status of patients and updating
the dentist or the patient about dental health during the interval between visits.
Aim. The article is aiming to explain the development of „Mobile dental hygienist app“ and to describe the
protocol assessing the usability of the app.
Methods. The mobile application usability assessment study will be conducted according to the study plan.
Starting with the selection of patients by inclusion criteria, a pilot study is conducted, followed by the main
study with three stages (T0; T1; T2).
Results. The newly developed mobile application titled “Mobile dental hygienist” is available to two types of
users: the patient and the oral care professional. A conversation with a specialist and self-evaluation
questionnaire are available choices for the patients on the menu. Dental hygienist receives information from the
patient in case the patient writes a message in the interview field or if he answers the questionnaire question in
the affirmative. “Mobile dental hygienist app” installed in personal mobile devices could be useful in improving
self – evaluation, the status of dental hygiene and oral health in general.
Conclusions. Technology innovations can potentially improve tooth brushing quality in children and adult
persons and increase self-awareness in oral health. Future research should continue to evaluate mobile
applications as part of intervention approaches to improve oral health behaviours and outcomes in vulnerable
populations.
Keywords: mobile application, oral health behaviour, research protocol, usability assessment.
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Medical Sciences 2023 Vol. 11 (3), p. 39-47, https://doi.org/10.53453/ms.2023.3.5
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1. Introduction
Mobile devices are considered as useful means to
deliver health interventions because of their
widespread adoption, powerful technical
capabilities, portability – people tend to have their
mobile phones on them at most times and form
strong emotional attachments to them. People
spend more time with their mobile phones than
with their partners or at work, meaning health
intervention can be delivered anytime and
anywhere [1].
Some features of smartphones that make them
suitable for behavioural interventions include: (1)
they are portable devices that are extremely popular
among people specially adolescents. (2)
Smartphone applications (apps) are a more
economical and favourable way of intervention. (3)
The capability of smartphones for a convenient
connection facilitates the distribution of health-
related information and provision of behavioural
interventions [2].
Chronic conditions are an increasing challenge for
individuals and the health care system.
Smartphones and health apps are potentially
promising tools to change health-related behaviours
and manage chronic conditions. – One of the
population-based surveys has found that 61.25 %
(2538/4144) of participants used a smartphone.
Compared with nonusers, smartphone users were
younger, did more research on the Internet, were
more likely to work full-time and more likely to
have a university degree and had a higher health-
related quality of life and health literacy. Among
smartphone users, 20.53 % (521/2538) used health
apps. The most common app characteristics were
planning (264/521, 50.7%), reminding (188/521,
36.1 %), prompting motivation (179/521 34.4 %),
and the provision of information (175/521, 33.6 %).
Significant associations were found between
feedback or monitoring and adherence to doctor's
advice. Health app use may reflect a user's
motivation to change or maintain health behaviours
[3].
Long-term health management is challenging for
the rapidly growing number of patients with
chronic diseases. Smartphone interventions offer
promising solutions.@The studies found that the
smartphone intervention was a completely or at
least partially effective tool to assist in managing
some chronic diseases. With the help of health-
related smartphone apps, patients with chronic
conditions (1) felt secure in the knowledge that
their illnesses were closely monitored, (2)
participated in their own health management more
effectively, and (3) felt that they had not been
forgotten by their doctors and were taken good care
of even outside the hospital/clinic@[4].
In the US, 56 % of citizens own a smartphone
capable of connecting to the internet and
downloading content [5]. About a quarter of
children use their smartphones more than 5 hours a
day, and about 46 % of teens aged 12-17 years surf
the internet for 4 hours a day (browsing from their
smartphones or computers) [6].
1.1. Mobile applications use for patient
education in dental medicine
Maintenance of self-care behaviours such as oral
hygiene can delay the onset of orofacial diseases
(primary prevention) or decrease or slow down
their effects when they become chronic (secondary
or tertiary prevention). In the first case,
interventions concern the field of health education,
while in the second they consist of patient
education actions and/or programmes. Patient
education actions can be short, while the
programmes are made up of several sessions over
time. The review of the recent scientific literature
on patient education in dentistry and dental hygiene
puts into evidence the limited number of
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publications on this topic, despite the need to use
patient education as a strategy of secondary or
tertiary prevention in several chronic oral diseases
and conditions. It has been shown, through the
analysis of a limited number of studies, that patient
education can bring real benefits to the patient at
both the bio clinical and psycho-cognitive levels:
overall, it allows them to better understand their
disease and the treatment and to improve their self-
care behaviour. The systemic literature review has
revealed some specific educational strategies being
implemented in patient education, such as
computer-assisted instruction in 3D video format,
YouTube, Webchat, face to face education using
motivational interviewing techniques, the practice
of manual dexterity and a short, structured diary
[7]. Also, new technology such as a Smart Mirror,
which have been developed to keep user fit and
healthy [8].
Recently, the novel coronavirus (COVID-19)
pandemic has highlighted the need for remote
communication when patients and dentists cannot
meet in person. Gingivitis is very common and
characterized by red, swollen, bleeding gums.
Gingivitis heals within 10 days of professional care
and with daily, thorough oral hygiene practices. If
left untreated, however, its progress may lead to
teeth becoming mobile or lost. Of the many
medical apps currently available, none monitor
gingivitis. The study aimed to present a
characterization and development model of a
mobile health (m-Health) app called iGAM, which
focuses on periodontal health and improves the
information flow between dentists and patients.
iGAM is the first mHealth app for monitoring
gingivitis using self-photography. iGAM facilitates
the information flow between dentists and patients
between check-ups and may be useful when face-
to-face consultations are not possible (such as
during the COVID-19 pandemic)@[9].
Due to apps being largely unregulated, the quality
and accuracy of the information provided can be
variable. In total, 1,075 apps were identified with
fewer apps available on the App Store than on
Google Play. The 20 most popular apps for each
search term focused on providing oral hygiene
information, were free of charge and were
developed after 2015. No apps contained
information regarding whether they were approved
by official organisations and if effectiveness or
acceptability testing had been conducted. App
ratings were variable and unrelated to the quality
and accuracy of the information. Due to a lack of
professional regulation, there is a risk that patients
may access inaccurate information via apps.
Therefore, evaluation, validation, and quality
assessment of healthcare apps is needed before
recommending these to patients [10].
The aim of the article is to explain the development
of Mobile dental hygienist app and to describe the
protocol assessing the usability of the newly
developed app.
2. Methods
2.1. Development of Mobile Dental Hygienist
Mobile Application
Mobile Dental Hygienist (further MDH)
application was created by following the
recommendations for mobile application creation,
adopted by the FDI General Assembly September
2018 in Buenos Aires, Argentina [11] stating that
dental health apps should be: developed following
thorough scientific literature analysis; using native
language of users; ensuring data safety; informative
about purpose of the app (diagnosis, treatment,
education or self-assessment); developed by dental
professionals and clearly declaring financial
interests of creators. The team of investigators
consisted of three dental hygienists (two of them
have PhD in public health), public health specialist,
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occupational therapist, PhD in education, dental
hygiene student and information technology
student. The MDH app was created after scientific
literature analysis, using the data bases PubMed
Medline with key words e-health, dental apps,
mHealth, Tele-dentistry, app usability etc. The
team of investigators created five questions for oral
health status self–evaluation, which were
introduced in this application. The five questions
representing main indicators of oral health status
(presence/absence of gingival bleeding, edema,
redness, bad breath, soft plaque and calculus). The
questions are illustrated with pictures, having only
two answer options YES/NO in Lithuanian
language. MDH app is not used for diagnosis and
treatment of periodontal diseases, and the patients
using this app receive this important information in
a process of downloading it. The app is developed
for educational and scientific purposes, so it is free
from advertising and developers have no financial
interests. For the purpose of verifying the
employee's personal login and the use and
management of data granted only to him, user
access is restricted with a login name and password
that are known only to the user and the person
administering the app.
The MDH app is available for two types of users:
the patient and the oral care professional. In the
first window of the MDH app, a user selection is
possible, going to the login field. The patient can
choose one out of three functions: a conversation
with a specialist or questionnaire or additional
information. The specialist can choose one out of
two functions: a patients’ list or additional
information. Dental hygienist receives information
from the patient in case the patient writes a
message in the interview field or if he gives at least
one affirmative answer to the self-evaluation
question. In the conversation field, the specialist
can contact the patient himself (Fig.1).
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2.2. Requirements for Research Environment
Patients will be examined by assessing OHI-S
(Oral Hygiene Index-Simplified) and GBI
(Gingival Bleeding Index) in a dental chair by
dental hygienist or dental hygiene students
supervised by a registered dental hygienist. In the
examination area high noise level, loud
conversations should be avoided. Subjects should
not be permitted to crowd around the examiner. A
complete examination of an adult patient may take
between 15 and 20 minutes. The examination will
be done in dental chair using plane mouth mirror,
explorer, and non-waxed dental floss@[12].
2.3. Research Design
The study will be conducted according to the
research design (Fig. 2). Starting with the selection
of patients by inclusion criteria, a pilot study is
conducted, followed by the main study with three
stages (T0; T1; T2).
Figure 2. Research design
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2.4. Pilot study
The purpose of the pilot study is to test the MDH
app and oral health behavior questionnaire. 10
voluntary patients will participate in this pilot
study. All ten participants will be using the MDH
app for 6 weeks. Before downloading the app to
their smartphones and after 6 weeks of using the
app, participants will be clinically assessed (OHI-S
and GBI indexes)@(Fig. 2).
Questionnaire about participants’ experiences with
the MDH app will be given to participants of a pilot
study (after 6 weeks of using the app). This
questionnaire will assess acceptability, operability,
attractiveness of the app; users’ perceptions of
several components of the app, intention to use the
app, perceived effectiveness, and usability. This
questionnaire will use the following 6-point scale:
0: not applicable, 1: very bad, 2: bad, 3: neither
good, nor bad, 4: good, 6: very good. Changes to
the app will be done according to this evaluation
after the pilot study (if participants of the pilot
study report any changes needed). The same
questionnaire will be given to an intervention group
participants in T2 stage of a main study (Fig. 2).
The Oral health behavior questionnaire will be
administered to the participants during pilot study
too. The first part of the questionnaire includes
questions on the participants’ demographic
background and any possible confounding
variables (age, sex, education level and smoking
status). The second part of the questionnaire
contains questions with both single-response and
multiple-response items on oral-health behaviors
and their psychosocial factors. This questionnaire
was derived from earlier study that tested the effect
of a smartphone application on oral-health behavior
and oral hygiene in adolescents with fixed
orthodontic appliances [13]. Participants will be
asked to report the frequency with which they use a
toothbrush, a proxy brush, dental floss, toothpicks,
mouth rinse, and other dental aids. It will use the
following 7-point scale: 1: less than twice a month
or never, 2: twice a month, 3: once a week, 4: two
to three times weekly, 5: once daily, 6: twice daily,
and 7: three times daily or more. For the analysis,
these response options will be recalculated to
establish the weekly frequencies of each of the
oral-health behavior. The same questionnaire will
be given to an intervention and control groups’
participants in stages T0 and T2 of a main study
(Fig. 2).
2.5. Baseline assessments in the main study
The main study participants will be included in the
study following the inclusion criteria (Fig. 2).
Randomization to the intervention group or control
group will be performed at the patients’ level. A
researcher who is not involved in data collection or
analysis, will use random sequence generator
(http://www.random.org) to allocate patients in a
random sequence to the intervention or control
group (30 participants in each group). In a separate
room after completion of the baseline assessments
(Fig.2), an independent researcher will inform each
participant to which group he/she has been
allocated. The persons assigned to an intervention
group, will be assisted in installing the MDH app
on their smartphone and will be provided with an
information on how to use it.
2.6. Clinical assessment
Clinical assessment of participants of the study will
be performed at T0, T1 and T2 stages of the study
(Fig. 2). Many plaque index systems have been
used to help improve patients' oral hygiene. A good
index system for daily practice must be simple and
versatile, so that it is easily understood by
inexperienced examiners and can be reproduced by
different clinicians [14]. Two indexes were chosen
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to be performed to assess patients’ oral health –
OHI-S and GBI.
Simplified Oral Hygiene Index (OHI-S) will be
used to evaluate patients' oral hygiene status. The
OHI-S, like the OHI, has two components, the
Debris Index and the Calculus Index. The six
surfaces examined for the OHI-S are selected from
the 4 posteriors and 2 anterior teeth. Criteria for
classifying debris: 0 no debris or stain present; 1
soft debris covering not more than 1/3 of the tooth
surface or presence of extrinsic stain without other
debris regardless of surface area covered; 2 soft
debris covering more than 1/3 but not more than
2/3 of the exposed tooth surface; 3 soft debris
covering more than 2/3 of the exposed tooth
surface. Criteria for classifying calculus: 0@No
calculus present; 1 Supragingival calculus covering
not more than third of the exposed tooth surface; 2
Supragingival calculus covering more than one
third but not more than two thirds of the exposed
tooth surface or the presence of individual flecks of
subgingival calculus around the cervical portion of
the tooth or both; 3 Supragingival calculus
covering more than two third of the exposed tooth
surface or a continuous heavy band of subgingival
calculus around the cervical portion of the tooth or
both.
Gingival bleeding is an objective, easily assessed
sign of inflammation that is associated with several
periodontal diseases [15].
Gingival Bleeding Index (GBI) [16]. This index
enables to determine the presence of disease by
observing bleeding of the gingiva. Bleeding upon
flossing indicates disease and this will help
determine the gingival/oral condition of the
patient’s mouth.
Analysis plan of the study results
The participants’ characteristics will be
summarized using descriptive statistics (mean,
standard deviation, frequency). Two analyses will
be performed: 1) to evaluate the overall
intervention effect, 2) to evaluate the intervention
effect at different follow-up times.
Ethical Considerations
The study protocol must be approved by the local
Bioethical Committee, ensuring the confidentiality
and informed consent of the investigated persons.
3. Discussion
The article describes the protocol to evaluate the
usability effectiveness of the Mobile dental
hygienist app. We hypothesize that this app will
cause greater improvements in oral health behavior
and oral hygiene outcomes (presence of dental
plaque, gingival bleeding), and finally motivate to
take better oral hygiene daily routine.
By making study objectives and methods known,
the publication of the study protocol will improve
the eventual usefulness of the study [17].
The process evaluation will provide additional
insight into the effective ingredients of the
intervention and into the feasibility of the
intervention for the target group. Understanding of
these issues will underlie the post-trial adjustments
necessary to enhancing the effectiveness of Mobile
dental hygienist app.
As we mentioned earlier, there is a lack of apps that
monitor gingivitis. Now in 2020, there are no
available mHealth apps that monitor the
periodontal status of patients, update the dentist or
the patient about dental health during the interval
between visits. To our knowledge, this is one of the
first studies evaluating technology innovations
which could improve and increase self –evaluations
in oral health in Lithuania.
This app will offer the patient not only to answer
into 5 questions, but also help them to contact with
dental hygienist for suggesting what to do next.
First, offers to evaluate oral health status; second,
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dental hygienist receives the data, professionally
evaluates them; third, offers a solution to improve
patients’ oral health condition.
We hope this system will gain very high
appreciations from both dental hygienists (or other
dental professionals) and patients who will confirm
its usefulness in dental services field. This system
could significantly help to rearrange patient
appointments, especially for those with sudden
worse of oral health. If dental hygienist could
monitor patients’ data regularly, the occurrence of
many problems related with oral health could be
reduced.
Good oral-health behavior should be maintained
continuously over a long period of time. As habit-
formation takes an average of 66 days [18], we
expect that our intervention will be long enough to
guarantee a long-term behavior change.
We should also mention some limitations of the
study. Data on oral-health behavior and its
psychosocial factors will be self-reported. Self-
reported measures are prone to bias. One more
limitation is that the participants in the control
group might also undergo some changes in oral
health behavior, which may conceivably be
induced by questions about their behavior.
Behavior can be increased or changed simply if
questions are asked about participants’ behavior
[19].
“Mobile dental hygienist” installed in personal
mobile devices could be useful in improving self –
evaluation, the status of dental hygiene and maybe
we can say even whole oral health. In addition, all
data can be used for further development and
improvement of the program and even further
research works.
4. Conclusions
Technology innovations can potentially improve
tooth brushing quality in children and adult persons
and increase self-awareness in oral health.
Innovative means need to be designed to achieve
long-term, sustained improvements in tooth
brushing and oral health. Future research should
continue to evaluate mobile applications as part of
intervention approaches to improve oral health
behaviours and outcomes in vulnerable
populations.
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