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Interactive oral hygiene instruction: and iPad application

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Interactive oral hygiene instruction: and iPad application

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Content INTERACTIVE ORAL HYGIENE INSTRUCTION:

AN IPAD APPLICATION

by

Michael C. Meru

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CRANIO-FACIAL BIOLOGY)

May 2012

Copyright 2012 Michael C. Meru
ii

Dedication

To Melissa & Elle Meru

iii

Acknowledgments

I am very grateful to the knowledge and assistance of Ryan Hungate who is a future USC
Orthodontic Resident and fellow Trojan, as well to the other members of our design team.

A special thank you to Dr. Sameshima for the inspiration, support, and assistance.

And thank you to Linda San Agustin and Judy Walter for all of the financial assistance.

And last but not least to my co-residents for ideas, feedback, and for being awesome!

iv

Table of Contents

Dedication ii

Acknowledgments iii

List of Figures v

Abstract vii

Chapter 1: Introduction: 1

Chapter Two: Materials and Methods: 12

Chapter Three: Discussion and Purpose of Application 16

Chapter Four: Next Steps 50

Chapter Five: Limitations 51

Chapter Six: Conclusion 52

References 53

v

List of Figures

Figure 1: Splash Screen 17
Figure 2: Main Title & Menu Page 18
Figure 3: Menu for Games 19
Figure 4: Menu for Quiz 20
Figure 5: Module 1 Instructions – Brushing 21
Figure 6: Module 1 – Brushing 22
Figure 7: Module 2 Instructions – Flossing 23
Figure 8: Module 2 – Flossing 24
Figure 9: Module 3 - Multiple Choice Questions on Interim Hygiene –
Instructions 25

Figure 10: Module 3 - Multiple Choice Questions on Interim Hygiene 26
Figure 11: Module 4 - Appropriate Diet While Wearing Braces – Instructions 27
Figure 12: Module 4 - Appropriate Diet While Wearing Braces 28
Figure 13: Module 5 – Rubber Band Wear – Instructions 29
Figure 14: Module 5 – Rubber Band Wear 30
Figure 15: Module 6 – Retainer Wear Multiple Choice Questions – Instructions 31
Figure 16: Module 6 – Question 1 32
Figure 17: Module 6 – Question 2 33
Figure 18: Module 7 (expanded version only) – Expander Care – Instructions 34
Figure 19: Module 7 (expanded version only) – Expander Care 35
Figure 20: Module Reinforcement Screen 36
Figure 21: PDF Certificate Email Page 37
vi

Figure 22: Certificate 38
Figure 23: Video Intro Page 39
Figure 24: Video Intro Page 2 40
Figure 25: Instructional Screenshot Example 1 41
Figure 26: Instructional Screenshot Example 2 42
Figure 27: Video 1 – Brushing 43
Figure 28: Video 2 – Flossing 44
Figure 29: Video 3 – Interim Hygiene 45
Figure 30: Video 4 – Appropriate Diet While Wearing Braces 46
Figure 31: Video 5 – Rubber Band Wear 47
Figure 32: Video 6 – Retainer Wear 48
Figure 33: Video 7 – Expander Use 49

vii

Abstract

Objectives: Current methods of orthodontic oral hygiene instruction include face-to-face
presentations, printed materials, videos, and other technologies. In an orthodontic setting
where the majority of patients are in their adolescence, these methods tend to bore them
and it is hard to keep their attention for a sufficient amount of time to properly instill
good oral hygiene techniques and principles. This project seeks to use methods and
technologies familiar and liked by them in order to have a more lasting effect on their
oral hygiene practices and behavior.

Purpose/hypothesis: To create a novel method to teach orthodontic oral hygiene
instructions using methods familiar and liked by adolescents, with the goal of aiding them
in the internalization of the principles through active participation such that it results in
better hygiene practices by these patients.

Procedures/Data/Observations: An iPad application was created using a team of
dentists, designers and computer programmers. Surveys and brainstorming sessions done
with experts in the field revealed which principles to be essential, as well as the types of
modules to place into the application.

Conclusions/Applications: The application created is the first of its kind in the world
and teaches adolescents in an interactive manner how to better care for their teeth. A
study on the efficacy of the iPad application will be performed in the future.

1

Chapter 1: Introduction

The oral health of all people is of great concern to the dental profession, but the oral
health and hygiene of orthodontic patients is critical due to the fact that orthodontic
appliances aid the oral environment in harboring greater concentrations of acid producing
bacteria
5
. The plaque and bacteria gather on the brackets, and due to their shape and
nature, are more difficult to maintain than the normal dentition
8,37,44
. The greater
concentrations then lead to, and are the principal cause of, gingivitis and enamel
decalcification in these patients
2,3,6,47
.

In order to deal with this increased risk for gingivitis and enamel decalcification
orthodontists have used many methods to teach patients proper oral hygiene techniques
while using orthodontic appliances. The techniques used to instruct these patients varies
between clinician and time period but began with simple chair side instruction. In 1976,
Clark et al. described the one on one discussion that should be had with a patient who has
poor oral hygiene while in the chair
8
. The method involved having the patient hold a
mirror to observe the assistant or doctor pointing out gingival conditions including
inflammation, plaque accumulation and bleeding. During this demonstration the patient
received detailed accounts of the harmfulness of the plaque and were even allowed to
look at it under a microscope. Then, the patient was shown proper brushing techniques on
a typodont. For a patient who has a better oral condition, a modified version of this
2

technique was used, using a typodont and chair side instructions. These oral hygiene
instructions were reinforced heavily throughout the course of treatment
8
.

Though traditional chair side instruction remains the most common technique used,
various other methods have been suggested involving differing techniques and
technologies. With orthodontic patients, these novel methods include: an intense multi-
week oral hygiene program (course)
33,49
, behavior modification using a reward system
41
,
written instructions
30
, videotape instructions
30
, and the use of the Hawthorne Effect
13
.

In 1980, Lundstrom et al. developed a course on proper plaque control that was given
three times over a period of 6 weeks with one follow up at 30 months. The results showed
that this course was effective in reducing gingival inflammation
33
. Yeung et al. developed
a similar course that met weekly for four weeks and had similar results
49
.

Richter et al. tested behavioral modification via the use of a reward system
41
. The sample
of 144 patients was divided into groups based on compliance, and one control. There
were no differences in oral hygiene scores with those who had below average and greater
scores with the control group, though those with low scores improved significantly as a
result the reward system
41
.

Lees et al. compared traditional face to fact oral hygiene instructions with those given by
written and videotaped means
30
. The results, though not significant most likely due to
3

sample size, showed that written means were ineffective in showing improvement,
though both the face to face and videotape means showed promise in teaching and
effecting change in proper oral hygiene techniques
30
.

Feil et al. studied the use of the Hawthorne Effect in improving oral hygiene
compliance
13
. The Hawthorne Effect is defined as an “unexplained result in an
experiment on human subjects, on the assumption that the result occurred simply because
the subjects were in an experiment and thereby experienced something that otherwise
would not have affected them.
13
” The researchers found that the group being studied
unknowingly created better oral hygiene habits due to their knowing they were being
studied.

While there are limited studies on oral hygiene instruction techniques in orthodontic
literature, there are numerous ones in dental literature. Techniques and technologies used
include: face to face instruction including the use of typodonts and pictorials
1,40
, audio-
visual instructions with the use of slides and audio-tapes
10,16,29,52
, television and video-
tape presentations
17,20,39,48
, motivational interviews
18
, robots, an interactive 3D
toothbrush, and web based technologies including blogs
19
and online courses
12
.

In the early 1970’s and 1980’s several groups of researchers, including Zaki et al.
52
,
Gjermo et al.
16
, Dreher et al.
10
, and Lachapelle et al.
29
, used sound and slide presentations
to teach oral hygiene. The Dreher and Lachapelle studies compared these methods to that
4

of traditional verbal instructions, and found the audio-visual techniques to be better
10,29
.
The results were no longer significant in the Lachapelle study after two months,
indicating that continued reinforcement is paramount in maintain good oral hygiene in
dental patients
29
.

Lim et al.
20
, and Glavind et al.
17
, both studied the use of television / video taped oral
hygiene instructions compared with traditional methods and found no difference in
plaque reduction. Lim et al. also compared this method to written instructions and again
found no significant difference in plaque reduction amongst patients in the study
17
.

Godard et al. studied the self-regulation theory and motivational interview for improving
oral hygiene and had good results
18
. The researchers conducted a motivational interview
with each patient that addressed the five dimensions of Leventhal’s theory and compared
to those taught with traditional oral hygiene instructions. Patients taught with the
motivational interview had greater improvement and satisfaction than those in the control
group
18
.

Rodrigues et al
42
. used three oral hygiene instruction techniques to teach school children
in Brazil. Group 1 consisted of indirect instruction via the Smiling Robot doll, group 2
received indirect instructions through a classroom presentation, and the third received
direct instruction with macromodels. The control group received no instruction at all. All
three experimental groups had decreased plaque scores, with the smiling robot having the
5

best results. The cohort felt that the smiling robot had the best results because it was
interesting to the children, and motivated them to listen to the presentation
42
.

Kim et al
27
. developed an interactive, high-tech means of teaching proper brushing
techniques via the use of 3D visualization with a smart toothbrush system. The system
first analyzes the patients brushing techniques and analyzes the waveforms generated
through a built-in accelerometer and magnetic sensor. A real-time display then shows the
patient what they may be doing wrong, and provides advice on how to correct their
mistakes
27
. To date, no studies have been conducted to determine efficacy of this method.

Two separate articles published in 2011 discuss the use of an online training program
12
,
and blog enabled peer-to-peer learning systems
19,
to teach proper oral hygiene techniques.
These studies show promise in the use of web 2.0, though since they were conducted
amongst medical students and dental hygiene students respectively, their efficacy has yet
to be shown amongst the typical dental and orthodontic patient.

These studies, as well as numerous others
4,24,25,43,46
, show that efforts made to engrain
principles of proper oral health care are beneficial to the patient though at varying levels
of efficacy. One can surmise that traditional methods have held strong across time as they
involve one on one interaction, whereas techniques that involve new technologies may
have receive increased excitement initially, though may dwindle more rapidly due to the
6

excitement of the technology being non-interactive, or the cost of it being too high to
support for the common practitioner.

For these reasons, this project aims to create a one-of-a-kind interactive oral hygiene
application that uses the most current technology that not only instructs on excellent oral
hygiene practices, but also engages the learner such that the principles are engrained and
put into practice.

One of the most widely used, and highly acclaimed devices of our time is the Apple iPad
and other mobile devices that support applications that can be taken anywhere with the
user
35
. Learning from these devices is termed, “m-learning
34
.” Though long term studies
showing their increased efficacy over traditional learning do not exist, numerous reports
and articles suggest there are great benefits to using the technology.

In 2011, Kinash et al
28
. reported on an empirical study where students were allowed to
use an iPad for their textbook, along with an application to assist learning. The feedback
received by the students was positive in that they enjoyed the method of learning, though
they weren’t convinced it made a significant difference in their learning
28
. Researchers in
this study felt that this may be due to the fact that the quality of the teaching didn’t
change as the same teacher, methods, and level of interactivity were used; it was merely
delivered via a different device.

7

Hall et al
36
. conducted a similar study with a group of graduate management education
students. Preliminary data from the study shows that the learning outcomes were similar
between the iPad and non-iPad groups, though those in the iPad group felt increased
convenience and flexibility, as well as felt good about their contributions to alleviating
paper waste in the environment. Other benefits noted by the author include; “affords an
integrated perspective on the course/program, presents instructional-rich content
including real-time feedback, offers courses designed for specific learning applications,
increases opportunities for student and team participation and interaction, improves
quality control through content integration, supports quality through learning assurance,
provides linkage with internet and library resources, and supports economic,
environmental, and energy sustainability.
36
”

The data in the previous two studies may be skewed as those being studied were all
college and post-graduate students who were motivated to get good scores and therefore
would have excelled regardless of the method of teaching. Our audience is a much
younger group, involving those from the ages of 6-16 (though the application was
designed to be able to be used by those older than that as well.)

In early research on the subject of tablets and mobile learning, Freake et al. showed that
electronic marking of physics assignments using a tablet PC was acceptable to students,
and effective as a learning tool. Though these devices were less mobile than the current
tablets available, they laid the groundwork for those being used now.
8

In a meta-analysis of articles on m-learning, e-learning, ubiquitous computing, iPad, and
mobile technologies, Murphy et al.
35
showed study outcomes during the past 5 years that
include increased physical access to content and greater connectivity, ubiquitous learning
environments and adaptable learning opportunities, greater student centric learning and
personalized training, enhanced productivity, better context specific data capture, an
increased facilitation of teamwork and collaboration amongst learners, as well as
increased portability
35
.

Despite promising results, long-term data still does not exist on the efficacy of the
technology. Feajii et al.
14
have developed a means to test the efficacy called Mobile
Learning Usability Attribute Testing (MLUAT) and we should see results in the near
future. Though means of testing now exist, the technology is ever changing in that new
innovations come about quite frequently so keeping the testing methods up to date with
changes may prove to be a very difficult task to undertake.

In the literature review conducted for this thesis, the researcher felt that two main areas of
study were missing that will be game changers in the way oral hygiene is taught. The first
is to use an interactive technology that doesn’t merely deliver the message in a new way,
but requires the learner to interact and receive feedback from the device. The second is to
use this tool on those who are more malleable in their thinking, ie: young children who
are not in a program or course that is mandated to receive a degree or certificate.

9

To the first point, years of research have shown that interactive teaching and interactive
and active learning enhance and can be superior to strictly one-way teaching. The 1999
the British National Numeracy Strategy called for whole class interactive teaching, and
defined interactive teaching as, “A two-way process in which pupils are expected to play
an active part by answering questions, contributing points to discussions, and explaining
and demonstrating their methods to the class
40
.” Yun et al. found via a literature review
that there are five positive information effects in interactive teaching, including; feedback
effect, attention enforcing effect, theory practice amalgamation effect, memory
facilitating effect, and innovation inspiring effect
51
. These effects, when properly used,
can increase the learning of the student.

Using interactive CDs to teach pre-school students, Eristi et al.
11
found that the high
levels of interaction employed by the CD tool promoted high quality interactions, it
improved the quality of instruction, allowed the user to individualize the instruction,
which increased the interest and motivation of the students, thus showing a correlation
between interactive instruction and increased learning
42
. Similarly KeJia et al
26
. Found
that multidimensional interactive teaching showed the students that they learning
revolved around them, which caused the students to think independently and seek further
information
26
.

In an excerpt from the Educating Young Children curriculum guide, Weikart et al. state
that children in an active learning setting, “initiate activities that grow from personal
10

interests and intentions
20
.” They continue by saying that active learning is a complex
physical and mental process and is truly the way children learn
20
. In an article by
Anuradha Shukla, he states that, “The most significant aspect about the nature of
interactive learning is that it induces the student to learn and know more by working with
the subject. They have to ask questions, search for answers, in short, they imbibe or
understand how a subject actually works by working at it themselves.
45
” A study by
Huang et al. confirms Shukla’s statement where they found that active participation in
interactive teaching environments produced more efficient learning
23
.

Interactive learning and teaching has over the years also involved the use of technology
to aide the process. In 2011, Li et al. reported that a web-based interactive teaching
system developed by and for them to teach core network technology courses delivered
similar or better lab experiences for the students, all while cutting costs
31
. In a healthcare
setting, where children with hearing loss were instructed with interactive multimedia
teaching tools, Yovkova et al. found that the performance and learning of students
improved significantly
50
.

Reports of blending the interactive and active learning culture with the use of videogame
technology have also been proposed
7
and reported
9,21
. In 2001 Din et al. studied the use
of educational PlayStation games on performance in other educational areas. The study
showed that those who played 40 minutes per day for 13 weeks had significantly higher
scores in spelling and decoding areas than those in the control group
9
.
11

In 2011, Hong et al. developed an embodied interactive video game with both
educational and entertainment components that was used to teach kindergarten age
students. The authors state that a mix of both traditional teach based learning combined
with the video game yielded the best results, and that the game “was highly entertaining,
which resulted in students remaining highly interested and focused throughout the
study
21
.”

Recently, schools and learning institutions have begun using the novel technologies such
as the iPad and other mobile devices with younger students, starting as early as
kindergarten
22
, and the results are promising.

Currently there are no technologies in the dental and orthodontic fields that combine an
interactive learning modality with a mobile device. This project creates the first
application of its kind using an interactive oral hygiene iPad application to teach
orthodontic patients proper care of their oral cavities.

12

Chapter 2: Materials and Methods

The initial step in creating the interactive oral hygiene iPad application was putting
together a team that could take the application from idea to product. After a nationwide
search for a team that fit a small budget, yet had the skills to produce a high class
application, a team of four was put together, including: a dental student with previous
background in iPad application design, a person with expertise in motion and iPad
coding, a graphic designer, and myself the orthodontic resident with the idea on where to
take the application.

During the first few phone calls and in-person meeting, the dental student and myself
reviewed all of the literature on the subject and looked into current methods being used
by the school and dental practices to teach oral hygiene to orthodontic patients. We also
held informal focus groups with residents to find out which portions of oral hygiene
education were essential to include in the application. From this information we compiled
a list of the items and modules we were to include, defined the target audiences of the
application, and designed the best means of laying out the app in order to better teach
those who would use the application.

Our research concluded that the interactive application should flow through a three-step
process. First, the learner would watch a series of short (1 minute or less) videos teaching
them the principles of oral hygiene. Second, they would play an interactive game that
13

would put into practice the principles taught during the videos. And finally, they would
take the game modules as a quiz to complete the process. It was also decided that
positive and constructive feedback throughout the process would be essential to the
success of the application.

We then conceptually drew out each module and separate screen of the application with
paper and pencil. The six main modules would include: proper brushing techniques with
braces, proper flossing techniques with braces, multiple choice questions on oral hygiene
while away from a toothbrush, proper diet while wearing braces, rubber band wear, and
the use of retainers once orthodontic treatment is concluded. We designed a seventh
module for the expanded version that would include instructions on how to use a palatal
expander.

Not only were the modules sketched and conceptually designed, but each screen of the
application was done as well. We designed the three separate menu pages that include:
the main menu, the games menu, and the quiz menu. We designed the positive feedback
screens that include and excellent thumbs up after each module, and a certificate that
would be sent to both the patient and doctor upon completion of the quiz, signifying that
the patient had complete the application successfully. We then designed the splash page
and backgrounds that would be used as a motif throughout the application. We also put
together what we wanted the video playback screens to look like.

14

Once the application was conceptually laid out and designed on paper, we met with both
coder and graphic designer to verify that what we wanted was possible. Once the
affirmative was given, we delivered the layout to them and waited for them to send us
design and functionality samples. The process of getting alpha samples and sending
feedback for modifications and then getting re-worked art and modules took a period of
nearly eight months.

The graphic designer designed the majority of graphics, though several food pictures for
the videos were purchased through a royalty free company. The two songs used, one for
the game and one for the videos was also purchased on a royalty free site. We also
included voiceover instructions for the modules as to allow those who had disabilities and
those who were to young to read well to be able to utilized the application. The younger
sister of the dental student did the voice for the voiceovers on all modules.

When both the dental student and I were satisfied with the artwork and module design,
the full application was put into a beta version and testing began. All four of those in the
group tested the application, as well as numerous friends, co-residents, patients, and
others. The incredible aspect of designing an application on an Apple platform is that the
application automatically gives feedback to coder as the beta is being used. For example:
when I was using the first beta version the application crashed about 10 times in the first
10 minutes of use. Each of those crashes sent an automatic report on where the crash
occurred and why to the coder. The coder was then able to go into the foundation of the
15

application and make changes that ensured that crashes in those locations would no
longer occur. That took place with each user, on numerous different iPads, and over a
period of seven or eight different beta versions, resulting in the application that we
currently have that rarely has any technical issues.

16

Chapter 3: Discussion and Purpose of Application
As noted in the previous chapter, each screen and page within the application has a
purpose, and the minimum number of pages was used to ensure that tedious pages and
needless instructions do not annoy the learner. The following figure pages are screenshots
of each page designed for the application. Including the video screens that appear as a
separate window above a showing screen, there are 32 unique pages included in the
application.

17

Figure 1: Splash Screen

The title of the application is Brae Says. We felt it is a fun play on the word “braces” and
since the learner will follow a girl named Brea through the application, it was fitting to
call it Brae Says.

The splash screen loads each time the application launches initially. Thus if a learner
leaves the application to go to another application, but doesn’t shut down, this will not
appear. It only appears when the application has been completely shut down and is re-
opened.

18

Figure 2: Main Title & Menu Page

This page is the main menu where the learner can access one of the three main conceptual
learning points within the application. Within the Games module learners will first watch,
and have access to all of the videos that are shown in the third menu item on this screen.

19

Figure 3: Menu for Games

This page allows patients to do one of three things. It allows them to play sequentially all
modules via standard play (without the rapid palatal expander module) or expanded play
(with the rapid palatal expander module). It also allows the patient to access each module
on its own in order to practice or remember a single technique. These are accessed by the
icons seen at the bottom of the screen.

20

Figure 4: Menu for Quiz

This page allows the learner to access to take the quiz for all modules via standard play
(without the rapid palatal expander module) or expanded play (with the rapid palatal
expander module). Once a learner has begun the quiz, they are unable to leave the quiz to
without quitting the entire quiz.

21

Figure 5: Module 1 Instructions – Brushing

Prior to the learner accessing each module, Brae appears and gives instructions on how to
play the individual module. The instructions are given in both a written and spoken
format. These instructions are for the brushing module.

22

Figure 6: Module 1 – Brushing

The brushing module asks the learner to use their finger as a toothbrush and use the
proper brushing strokes that were taught during the instructional video to remove the
plaque and food debris on the teeth. The application has motion detection that will
provide feedback to the learner if they are using strokes that could damage the gums or
braces.

23

Figure 7: Module 2 Instructions – Flossing

This page is the instructional page on the flossing module. The instructions are also
given in an audio format.

24

Figure 8: Module 2 – Flossing

In this module, the patient is asked to use their finger to show the proper direction and
location of floss placement during flossing. The key here is to show that it not only
passes through the contact, but goes on both sides of the papilla.

25

Figure 9: Module 3 - Multiple Choice Questions on Interim
Hygiene – Instructions

This page is the instructional page on the multiple-choice questions for interim hygiene
module. The instructions are also given in an audio format.

26

Figure 10: Module 3 - Multiple Choice Questions on Interim
Hygiene

This page contains a series of multiple-choice questions on the use of interim hygiene
devices that the learner received instructions about during the interim hygiene
instructional video.

27

Figure 11: Module 4 - Appropriate Diet While Wearing Braces –
Instructions

This page is the instructional page how to complete the module on proper diet while
wearing braces. The instructions are also given in an audio format.

28

Figure 12: Module 4 - Appropriate Diet While Wearing Braces

In this module the patient is asked to drag foods that are good for Brae’s braces to her,
and those that aren’t to the trash. A series of foods appear including: an apple, apple
slices, popcorn, nuts, candy, chicken, and numerous others.

29

Figure 13: Module 5 – Rubber Band Wear – Instructions

This page is the instructional page on the rubber bands module. The instructions are also
given in an audio format.

30

Figure 14: Module 5 – Rubber Band Wear

In this module the learner is shown the proper placement of the rubber bands and is asked
to repeat the process in order to engrain in them that thought the rubber band placement
may change, they should always follow their orthodontists instructions on wearing rubber
bands in order to facilitate their treatment.

31

Figure 15: Module 6 – Retainer Wear Multiple Choice Questions -
Instructions

This page is the instructional page on the retainers module. The instructions are also
given in an audio format.

32

Figure 16: Module 6 – Question 1

(screen shot from Beta – questions now reads: “After your braces are removed, how
many months do you wear your retainers full time?”)

The first question asked is, “After your braces are removed, how many months do you
wear your retainer full time?” The appropriate answer is 6-months.

33

Figure 17: Module 6 – Question 2

The second question is, “How long after the first 6-months do you wear your retainer at
night?” The correct answer is FOREVER.

34

Figure 18: Module 7 (expanded version only) – Rapid Palatal
Expander Care – Instructions

This page is the instructional page on the rapid palatal expander Care module. The
instructions are also given in an audio format.

35

Figure 19: Module 7 (expanded version only) – Rapid Palatal
Expander Care

This module teaches the learner where to place the key and asks them to turn the
expander in the proper direction. The learner must turn the key twice and each time the
expander is turned, the jaw, expander, and teeth actually expand.

36

Figure 20: Module Reinforcement Screen

Upon completion of each module the patient sees a reinforcement screen telling them
they did an excellent job. This is the screen from a single module. When it is during a
quiz or full lesson, there is both a back and forward button.

37

Figure 21: PDF Certificate Email Page

Upon completion of an entire quiz the learner receives a certificate that states,
“Congratulations YOU Rock!” Their name is then inserted and it states, “This certifies
that ____________ is awesome and has mastered the fine art of great oral hygiene while
wearing braces through the mentorship of Brae Says!” The certificate also has the contact
information of the treating doctor. Once the learner pushes send, the certificate is sent to
their email address, and a note is sent to the doctor indicating that the learner has
completed the quiz portion of the application.

38

Figure 22: Certificate

Close up of Certificate

39

Figure 23: Video Intro Page

Each instructional video that appears has an introduction page that has the same text, with
a variation on color scheme. This is one example.

40

Figure 24: Video Intro Page 2

A second example of a video introduction page.

41

Figure 25: Instructional Screenshot Example 1

Each video is introduced and narrated by resident Michael C. Meru. This is the first of
two example screen shots.

42

Figure 26: Instructional Screenshot Example 2

The second of two example screenshots of the narrator.

43

Figure 27: Video 1 – Brushing

Video one deals with proper brushing while using braces. The animations for each video
come from Dolphin Imaging’s Aquarium software. A consult with Dolphin Imaging
revealed that since the Ostrow School of Dentistry of USC has a full license of the
software, that we could use the animations as we saw fit and could monetarily gain from
the application without owing any royalties to the company.

This video is 50 seconds long.

44

Figure 28: Video 2 - Flossing

Video two deals with proper flossing while wearing braces. This video is 54 seconds
long.

45

Figure 29: Video 3 – Interim Hygiene

Video three deals with interim hygiene while wearing braces. This video is 69 seconds
long.

46

Figure 30: Video 4 – Appropriate Diet While Wearing Braces

Video four deals with proper a learners appropriate diet while wearing braces. This video
is 62 seconds long.

47

Figure 31: Video 5 – Rubber Band Wear

Video five deals with wearing rubber bands during orthodontic treatment. This video is
52 seconds long.

48

Figure 32: Video 6 – Retainer Wear

Video six deals with proper retainer wear and care after braces are removed. This video is
57 seconds long.

49

Figure 33: Video 7 – Expander Use

Video seven deals with how to properly use and care for a palatal expander. This video is
45 seconds long.

50

Chapter Four: Next Steps

Now that Brae Says has been completed and the application itself is ready to come out of
its beta infancy to arrive as a version 1.0, its efficacy in engraining proper principles of
good oral hygiene is ready to be tested. The application is to be placed into the Apple
App Store where it will be a free download for all interested learners and doctors.

The continuation of the testing of Brae Says would make for another good research
project for a future resident. In looking at the research previously done by others in fields
outside of dentistry, one would hypothesize that it would be an effective means of
teaching patients proper oral hygiene, though only a properly designed research study
could verify that.

The benefit offered by studying the efficacy is two fold. First, it would add credibility to
the research and projects done within the Orthodontic Department at USC, and second, it
would be a great advertising point when encouraging practioners to use this in their
practices.

51

Chapter Five: Limitations

This project was created on a budget during a limited amount of time. That said, I believe
that the product is world-class and can stand the test of time within the technology
community. That said, the major limitations we have are two. First, we need to complete
the efficacy study noted previously. Once this is complete we will know whether or not
this application can be a paradigm shift in the way oral hygiene is taught to orthodontic
patients. Second, in order to market this tool, a sufficient amount of financial backing is
needed to properly market the application. Once the finances are met, I believe the
application has the potential to go viral in the orthodontic and dental communities and.

52

Chapter Six: Conclusions

The research leading up to the creation of this one-of-a-kind application was very
promising in that it supported and proved that active and interactive learning is an
exceptional and often times superior way to learn, and that technological devices can
often promote increased attention and interest. Though further studies in the field are
ongoing and need to be conducted to significantly conclude the latter statement, the
literature does currently support the idea of interactive learning with current state-of-the-
art technologies and techniques.

Currently there are no interactive mobile applications that teach oral hygiene of any sort,
and definitely not in the field of orthodontics. With the feedback already received from
patients, co-residents, and doctors, there is indeed room in the market for a tool such as
this. With the design and interactive innovations with Brae Says, this application has the
potential to be the gold standard for teaching oral hygiene by non-traditional means.

It was an honor to work on this project.

53

References

1. Addy M, Edmunds S. Effectiveness of methods of teaching dental health to 9- to
10- year old schoolchildren in the United Kingdom. Community Dental Oral
Epidemiology. Sep;5(5):191-194. 1977.

2. Alexander SA. Effects of orthodontic attachments on the gingival health of
permanent second molars. American Journal of Orthodontics and Dentofacial
Orthopedics. Vol. 100, #4, pg 337-340. October 1991.

3. Alstad S, Zachrisson BU. Longitudinal study of periodontal condition associated
with orthodontic treatment in adolescents. American Journal of Orthodontics. Vol.
76, No. 3, September 1979. Pg. 277-286.

4. Ay ZY, Sayin MO, Ozat Y, Goster T, Atilla AO, Bozkurt FY. Angle
Orthodontist. Vol 77, No. 6, pg 1085-1089, 2007.

5. Balenseifen JW. Study of dental plaque in orthodontic patients. Journal of Dental
Research. Vol 49, pg 320-324, 1970.

6. Chang HS, Walsh LJ, Freer TJ. Enamel demineralization during orthodontic
treatment. Aetiology and prevention. Australian Dental Journal. 1997;42:5. Pg
322-327

7. Chen JH, Wang TH, Chang WC, Chao LR, Shih TK. Developing an interactive
video game-based learning environment. Journal of Software, Vol.4, No. 2, pg
132-139, April 2009.

8. Clark JR. Oral hygiene in the orthodontic practice: Motivation, responsibilities,
and concepts. American Journal of Orthodontics, Vol. 69, pg 72-82, January
1976.

9. Din FS, Calao J. The effects of playing educational video games on kindergarten
achievement. Child Study Journal. Vol. 31, No. 2, pg 95-102, 2001.

10. Dreher H, Graehn G. Slide audiotape series for dental health education. Stomatol
DDR. May: 29(5): 412-416. 1979.

11. Eristi SD. The effectiveness of interactive instruction CD designed through the
pre-school students. Journal of Theoretical and Applied Information Technology.
Pg 832-839, 2008.

54

12. Eskenazi ES, Martins MA, Ferreira M. Oral health promotion through an online
training program for medical students. Journal of Dental Education. Vol. 75, No.
5. May 2011.

13. Feil PH, Grauer JS, Dadbury-Amyot CC, Kula K, McCunniff MD. Intentional use
of the Hawthorne effect to improve oral hygiene compliance in orthodontic
patients. Journal of Dental Education. Vol. 66, No. 10, pg 1129-1135. October
2002.

14. Fetaji B, Ebibi M, Fetaji M. Assessing effectiveness in mobile learning by
devising MLUAT (Mobile Learning Usability Attribute Testing) methodology.
International Journal of Computers and Communications. Vol. 5, No. 3, 2011.

15. Freake S. Electronic marking of physics assignments using a tablet PC. New
Directions. No. 4, December 2008, pg 12-16.

16. Gjermo P. Audio-visual motivation and oral hygiene instruction. The effect upon
gingival status and oral cleanliness in 15 years old children. Odontol Revy. 23;(2):
253-262, 1972.

17. Glavind L, Zeuner E. Evaluation of a television-tape demonstration for the
reinforcement of oral hygiene instruction. Journal of Clinical Periodontology. Vol
13, pg 201-204. 1985.

18. Godard A, Dufour T, Jeanne S. Application of self-regulation theory and
motivational interview for improving oral hygiene: a randomized controlled trial.
Journal of Clinical Periodontology. 38:1099-1105. 2011.

19. Hanson K. Blog enabled peer-to-peer learning. The Journal of Dental Hygiene.
Vol. 85, No. 1, Winter 2011.

20. Hohmann M, Weikart DP. Educating Young Children: Active Learning Practices
for Preschool and Child Care Programs. Educating Young Children, a curriculum
guide from High/Scope Educational Research Foundation. Pg 13-41, 1995.

21. Hong JC, Tsai CM, Ho YJ, Hwang MY, Wu CJ. Interactive Learning
Environments 2011. Publisher: Routledge. Pg 1-15.

22. Hu W. Math that moves: schools embrace the iPad. The New York Times,
January 4
th
, 2011.
http://www.nytimes.com/2011/01/05/education/05tablets.html?pagewanted=all
Accessed 2/28/2012.
55

23. Huang R, Ma J. An agent based approach for promoting interactive teaching and
active learning. Information Technology Based Higher Education and Training –
9
th
International Conference, 2010. Pg 349-354.

24. Kakudate N, Morita M, Sugai M, Kawanami M. Systematic cognitive behavioral
approach for oral hygiene instruction: a short term study. Patient Education and
Counseling. Vol 74, pg 191-196, 2009.

25. Kang BH, Park SN, Sohng KY, Moon JS. Effect of a tooth-brushing education
program on oral health of preschool children. Journal of Korean Academic
Nursing. Vol. 38, No. 6, 914-922, 2008.

26. KeJia BAI. Research on Multidimensional Interactive Teaching and Application
in Database System Concepts Course. Trans Tech Publications 2011.
www.scientific.net/AMR.271-273.1253 Accessed 2/28/2011.

27. Kim KS, Yoon TH, Lee JW, Kim DJ. Interactive toothbrushing education by a
smart toothbrush system vai 3D visualization. Computer Methods and Programs
in Biomedicine. Vol. 96, pg 125-132. 2009.

28. Kinash S, Brand J, Mathew T, Kordyban R. Uncoupling mobility and learning:
when one does not guarantee the other. Teaching and Learning Papers. Paper 25.
http://epublications.bond.edu.au/tls/25. Accessed 2/28/2011.

29. Lachapelle D, Desaulniers G, Bujold N. Dental health education for adolescents:
assessing attitude and knowledge following two educational approaches.
Canadian Journal of Public Health. Sep-Oct; 80(5):339-344. 1989.

30. Lees A, Rock WP. A comparison between written, verbal, and videotape oral
hygiene instruction for patients with fixed appliances. Journal of Orthodontics.
Vol. 27, pg 323-327, December 2000.

31. Li C. Developing web-based interactive teaching system for core network
technology courses. International Transaction Journal of Engineering,
Management, & Applied Sciences & Technologies. Vol. 2, No. 5, Pg 483-492,
2011.

32. Lim LP, Davies WIR, Yeun KW, Ma MH. Comparison of modes of oral hygiene
instruction in improving gingival health. Journal of Clinical Periodontology. Vol.
23, pg 693-697, 1996.

33. Lundstrom F, Hamp SE. Effect of oral hygiene education on children with and
without subsequent orthodontic treatment. Scandinavian Journal of Dental Res.
1980: 88:53-59.
56

34. Manuguerra M. Promoting student engagement by integrating new technology
into tertiary education: the role of the iPad. Journal of Asian Social Science. Vol.
7, No. 11, pg. 61-65, 2011.

35. Murphy GD. Post-PC devices: A summary of early iPad technology adoption in
tertiary environments. E-Journal of Business Education & Scholarshiop of
Teaching. Vol. 5, No. 1, pg 18-32, 2011.

36. Owen HP, Smith DM. Assessing the role of mobile learning systems in graduate
management education. ICHL 2011 Proceedings of the 4
th
International
Conference on Hybrid Learning. Pg 279-288.

37. Parker RB. Our common enemy, Journal of the American Society for
Preventative Dentistry. Vol.1, pg 14-29, 1971.

38. Pratt N. Childrens’s Perceptions of Whole Clss Interactive Teaching: ‘Mental-
Oral’ or ‘Mental-Aural’? Proceedings of the British Society for Research into
Learning Mathematics. Vol. 23, No. 2, pg 73-78, June 2003.

39. Radentz WH, Barnes GP, Kenigsberg HS, Carter HG. Teaching dental flossing to
patients via television reinforced by individual instructions. Journal of
Periodontology. July;46(7):426-429. 1975.

40. Riccioli GA. Teaching photographs and diapositives of certain effectiveness in
explaining notions of dental hygiene, conservation, prosthetics and orthodontics
to patients. Mondo Odontostomatology. Sep-Oct; 13(5):811-813. 1971.

41. Richter DD, Nanda RS, Sinha PK, Smith DW. Effect of behavior modification on
patient compliance in orthodontics. The Angle Orthodontist. Vol. 68, No. 2., 123-
132, 1998.

42. Rodriques JA, dos Santos PA, Garcia PPNS, Corona SAM, Loffredo LCM.
Evaluation of motivation methods used to obtain appropriate oral hygiene levels
in schoolchildren. International Journal of Dental Hygiene. Vol 1, pg 227-232.
2003.

43. Rodrigues JA, dos Santos PA, Baseggio W, Corona SAM, Palma-Dibb RG,
Garcia PPNS. Oral hygiene indirect instruction and periodic reinforcements:
effects on index plaque in schoolchildren. Journal of Clinical Pediatric Dentistry.
Vol. 34, No. 1, pg 31-34, 2009.

44. Schwaninger B, Vickers-Schwaninger N. Developing an effective oral hygiene
program for the orthodontic patient: Review, rationale, and recommendations.
American Journal of Orthodontics. Vol. 75, No. 4, April 1979. Pg. 447-452
57

45. Shukla A. Interactive learning and its use in Asian educational institutions. Asia –
Pacific Business & Technology. http://www.biztechreport.com/story/151-
interactive-learning-and-its-use-asian-educational-institutions. Accessed
2/28/2011.

46. Smiech-Slomkowska G, Jablonska-Zrobek J. European Journal of Orthodontics.
Vol. 29, pg 157-160, 2007.

47. Sukhia HR, Ayub M, Ghandhi D. Enamel decalcification in orthodontic patients:
prevalence & oral distribution – a cross sectional study. Pakistan Oral & Dental
Journal Vol 28, No. 2, pg 193-197. December 2008.

48. Vande Voorde HE. A movie vs. chairside instruction to present preliminary oral
hygiene information. Journal of Periodontology. May;43(5):277-280. 1972.

49. Yeung SCH, Howell S, Fahey P. Oral hygiene program for orthodontic patients.
American Journal of Orthodontics and Dentofacial Orthopedics. Vol. 96. No. 3,
pg 208-213. September 1989.

50. Yovkova BS. Interactive instructional multimedia in vocabulary development of
children with hearing loss. International Conference “ICT for Language
Learning” 3
rd
Edition.

51. Yun C, Kefan X, Haimei L. Information effect in interactive teaching. CSEE
2011, Part V, CCIS 219, pp. 496-500, 2011.

52. Zaki HA, Bandt CL. Effectiveness of audiovisual machines in teaching oral
hygiene. Journal of Dental Education. Jul; 35(7):423-426. 1971.

Abstract (if available)

Abstract Objectives: Current methods of orthodontic oral hygiene instruction include face-to-face presentations, printed materials, videos, and other technologies. In an orthodontic setting where the majority of patients are in their adolescence, these methods tend to bore them and it is hard to keep their attention for a sufficient amount of time to properly instill good oral hygiene techniques and principles. This project seeks to use methods and technologies familiar and liked by them in order to have a more lasting effect on their oral hygiene practices and behavior. ❧ Purpose/hypothesis: To create a novel method to teach orthodontic oral hygiene instructions using methods familiar and liked by adolescents, with the goal of aiding them in the internalization of the principles through active participation such that it results in better hygiene practices by these patients. ❧ Procedures/Data/Observations: An iPad application was created using a team of dentists, designers and computer programmers. Surveys and brainstorming sessions done with experts in the field revealed which principles to be essential, as well as the types of modules to place into the application. ❧ Conclusions/Applications: The application created is the first of its kind in the world and teaches adolescents in an interactive manner how to better care for their teeth. A study on the efficacy of the iPad application will be performed in the future.

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Asset Metadata

Creator Meru, Michael C. (author)

Core Title Interactive oral hygiene instruction: and iPad application

School School of Dentistry

Degree Master of Science

Degree Program Craniofacial Biology

Degree Conferral Date 2012-05

Publication Date 04/26/2012

Defense Date 03/05/2012

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag dental,Dentist,dentistry,electronic learning,flossing,iPad,iPod,m-learning,mobile learning,OAI-PMH Harvest,OHI,oral hygiene,orthodontics,orthodontist,Tooth brushing

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Paine, Michael L. (committee chair), Enciso, Reyes (committee member), Sameshima, Glenn T. (committee member)

Creator Email meru@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-14017

Unique identifier UC11290340

Identifier usctheses-c3-14017 (legacy record id)

Legacy Identifier etd-MeruMichae-657.pdf

Dmrecord 14017

Document Type Thesis

Rights Meru, Michael C.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA