Smart Smiles in “Go Go Brush” App.: Technical and Clinical Insights into an Arabic Preschooler-Friendly Oral Hygiene Mobile App.

1. Introduction

Oral health promotion plays a crucial role in overall well-being and health. Dental and oral hygiene influence the incidence of dental diseases by fostering environments conducive to cariogenic bacteria and plaque formation [1]. Microbial plaque is well-documented in initiating and progressing dental caries and periodontal disease. Mechanical plaque removal, primarily through tooth brushing, remains the safest preventive therapy [2]. Dental caries are the most prevalent chronic disease in children globally and are considered a significant public health issue [3]. This multifactorial sucrose-dependent disease involves the progressive destruction of dental tissues' mineral structure, controlled by limiting sugar intake and mechanically disrupting dental biofilm through oral hygiene. Early tooth decay, coinciding with the eruption of baby teeth, leads to malfunctions, malnutrition, and growth and communication disorders [4].

Maintaining oral hygiene or oral self-care, which includes using toothbrushes, dental floss, and other interdental aids, is vital for overall health, socialization, and well-being. Brushing twice daily with fluoride toothpaste is essential for preventing early childhood dental decay and promoting good habits. Oral health care providers are key in promoting oral hygiene among children. However, optimal oral hygiene is challenging due to motivational factors and the need for initial dental assessments between 6 and 12 months of age [5].

Tooth brushing is acquired during a child's socialization process [6]. When taught early, it becomes a routine habit reinforced positively [7]. Despite this, tooth brushing in children under ten is often inadequate. Innovative health behavior interventions, like smartphone mobile applications, are emerging to encourage proper tooth brushing [8].

Smartphone applications have surged in popularity, with one-third of the global population owning smartphones by 2018. Games account for a significant portion of these downloads [9]. Mobile health, leveraging mobile phones and wireless technology, enhances telemedicine, data collection, decision-making, and emergency responses, improving patient condition control and treatment compliance [11].

Health applications manage various conditions, including diabetes [12], asthma [13], pain [14], and dermatological issues [15]. The rapid growth of mobile technology has led to mobile learning trends in health education, motivating and impacting oral health interventions and preventive care [10, 16-18].

Ferrazzano et al. [19] conducted a three-month study with 4-16-year-old children wherein prizes were used as motivation for the children to improve their oral hygiene. They concluded that maintaining prize incentives would help children to form better dental hygiene practices.

In 2017, Sadana et al. [20] examined four groups of school children aged 10-12 with their tooth-brushing technique instructed differently. The score for the plaque was most considerably organic for the group with audiovisual aids combined with verbal communication.

Subburaman et al. [21] compared musical toothbrushes to standard ones in 100 children, showing better debris and gingival bleeding scores with musical toothbrushes over three months. Yldrm and Kayaalt [22] in 2020 studied numerous methods of motivation on the indexes of plaque and gingival fold in children aged 6 to 12 years: all groups under the condition of music videos improved more than just a little.

Akkaya and Sezic, [23] demonstrated the effect of playful learning activities on 100 preschool children, stating that toys and songs worked wonders to improve behaviors and reduce plaque level scores.

2. Materials and Methods

2.1. Utilization of mobile health application.

The World Health Organization specifies mobile health applications as programmes for enhancing physical, mental, and social well-being [24], about 81% of phone owners aged 13 to 18 and 88% of those aged 16 to 24 have smartphones [25, 8].

Mobile health has grown rapidly in accessibility and has elevated telemedicine into yet another phase through improvement in data collection, integration, decision-making, and compliance of patients [26].

Individuals’ attachment to their phones facilitates health interventions [27-29]. These apps target a broad audience, including healthcare professionals and patients [30]. Mobile health has proven effective in managing various conditions like diabetes [31], asthma [32, 33], pain [34], and dermatological issues [35]. Their effectiveness was also demonstrated during the COVID-19 pandemic [36-38].

2.2. Mobile health applications for oral hygiene promotion.

Applications for Oral Hygiene Promotion in Mobile Health: Many children, as well as adults who brush their teeth, do not do so in a proper manner, and mobile health apps designed to motivate people are a really common tool. While apps are rather new means of encouraging people to brush their teeth, only limited research has been conducted on their effectiveness [8]. The reviews have shown that most popular mobile health apps are of poor quality. That opens a door for many more apps that follow good design principles and promote oral health with efficiency [39].

A systematic search of the app stores found only 17 out of 612 (about 3%) relevant apps using game-based learning to facilitate dental self-care among children [5]. Popular dental apps like “Brush DJ and Brush Up are very common apps [40].

In the study of Underwood et al. 2015 [25], the perception of users about the Brush DJ app was undertaken, and it was found that they consider it quite a potential motivator for evidence-based practices in oral hygiene.

The app “1, 2, 3. Brush!” [16] was developed in 2019 by Campos et al. to target preschool children with a specific focus on diet and oral hygiene. In efficiency, satisfaction, and effectiveness, the app showed positive results with 43 Brazilian children.

Zotti et al. 2019 [41] assessed the games Time2Brush and Brusheez and found that during the follow-up period over a year, the study group had much better oral hygiene and parental education compared to the control group.

Jacobson et al. 2019 [42] studied the Brush Up game app in children aged 5 to 6 years and found that there were considerable improvements in tooth brushing time and distribution over a week.

Alkilzy et al. 2019 [43] studied a smartphone app featuring a gravity sensor among 49 children aged 5 to 6. It was found that plaque index and papillary bleeding significantly improved in the group that had used the app.

Cazaux et al. 2019 [44] followed 52 autistic children for eight months using the çATED app. This study demonstrated the effectiveness of the app in regards to toothbrushing behavior. Desai RV et al. 2020 [2] conducted a study of the Brush Up app in Bengaluru involving 247 children between the ages of 4 to 6. The app exhibited greater effectiveness in plaque control in comparison to the videos and manuals.

Desai RV et al. 2020 [2] examined the effects of the Brush Up mobile application on the oral hygiene practices of children in Bangalore. A total of 247 children aged 4 to 6 were randomly assigned to three groups. Group I (n=82) used the Brush Up app, Group II (n=83) received instructional videos, and Group III (n=82) was given manuals. Plaque scores were measured for all groups at baseline and after one month using the Modified Visible Biofilm Index [45]. The Brush Up group had a lower plaque score at the second follow-up, indicating that the app effectively improved children's brushing techniques and plaque control through reinforcement and motivation. Sharififard et al. 2020 [46] used music and games to teach oral hygiene to visually impaired children. Oral health conditions were substantially improved by the ATP method.

3. Materials and Methods

3.1. Design and Development of “Go Go Brush” Application

3.1.1. General description

The Go Go Brush app was developed for Android devices through participatory design meetings. The app, supporting Arabic, was created using Kotlin, Firebase Cloud, Google ML Kit, and Unity. It aimed to motivate children to clean their teeth and improve mothers’ oral health knowledge with features like notifications, games, and educational content (Figure 1).

3.1.2. Analysis of the application

A block diagram described the app concept to the programming team (Figure 2).

3.1.3. Design of Go Go Brush: The app includes:

• Screens description:
• The splash screen is the first screen users see, displaying a logo and start button (Figure 3).

• Educational video: A mandatory, one-minute video explaining the Fones' circular tooth brushing technique in Egyptian Arabic (Figure 4).

• Login screen: Options to sign in and log in, with fields for email, password, and child’s information (Figure 5 and Figure 6).
• Home screen: Features three buttons:
• Get Brushing: Uses the camera with an animal filter and timer for brushing, turning a star light yellow after brushing (Figure 7Figure 8 and Figure 9).
• Play: Unlocks four games after brushing once a day (Figure 10).
• Choose a cap: New caps unlock weekly for consistent brushing (Figure 11).
• Games menu: Four games designed to motivate children about dental health:
• Catch Food: Selects healthy foods to gain points (Figure 12).
• Pac-Man style game: Modified for dental health, with a tooth character avoiding bacteria (Figure 13).
• Space Tooth: A tooth character uses toothpaste to destroy bacteria (Figure 14)
• Settings screen: Accessible only to parents, includes seven options:
• Prove yourself: Educational questions promoting parental awareness (Figure 16).
• Watch the intro video: Replays the educational video (Figure 4).
• Questionnaire screens. Figure 17
• Brushing settings: Controls brushing time from 30 seconds to two minutes (Figure 18).
• Change user: Allows adding and switching between multiple children (Figure 19).
• Language: Switches between Arabic and English versions of the app (Figure 20).
• Privacy policy: Views the app's privacy policies (Figure 21).
• Log out: Logs out the user.

3.1.4. The Followed “Design for children’ guidelines, principals and standards” in Go Go Brush

3.1.5. Applying the Game-Based Learning and Gamification Techniques in Go Go Brush Application.

Game-based learning allows children to learn concepts through fun and competitive games, enhancing learning outcomes. It involves using real objects and internet games, either individually or in groups. The distinction between gamification and game-based learning includes.

• Gamification is not competitive, while game-based learning is.
• Gamification incorporates game design elements into traditional learning environments to increase engagement.
• Awards are given in gamification for accomplishing objectives.
• Gamification involves a series of tasks, while game-based learning has goals and rules.
• Game-based learning requires more time and resources to develop.

The Go Go Brush application integrates both techniques.

• Gamification for task completion rewards.
• Game-based learning through actual games to teach dental concepts.

3.1.6. Algorithm and Methodology of Face Recognition.

The Pearson Correlation Coefficient, symbolized by r, is used to measure the linear relationship between two variables [48].

• Augmented Reality: AR enhances a real-world environment with virtual information, improving user interaction and sensory experience. It benefits both indoor and outdoor use by enhancing user contact with the real world [49].

3.2. Methodology

3.2.1. Sampling

• Ethical considerations: Ethical approval for this study was obtained from the Mansoura Research Ethics Committee, Faculty of Dentistry, Mansoura University (code number: A03051021). Informed consent was obtained from parents for their children's participation.
• Sample size calculation: The sample size was calculated with 5% significance and 95% power using G*Power 3.1.9.7, based on [4]. The mean practice score before intervention was 13.69 (SD=3.89) and after intervention was 16.02 (SD=3.48). The sample size was increased to 172 participants from an initial 110.
• Study population: From 230 screened children, 172 (84 girls, 88 boys) were selected based on inclusion criteria: normal mentality, age 4-6 years, and having a smartphone. Exclusion criteria included systemic diseases (e.g., diabetes), history of anxiety disorder, and plaque index score less than two.
• Study procedure: Participants were divided into a study group (122 children, 59 girls, 63 boys) and a control group (50 children, 25 girls, 25 boys). The study included a clinical part and a questionnaire, with follow-ups at baseline, one week, and one month.

3.2.2. Clinical part.

First visit.

• Ensure the child meets the inclusion criteria.
• Parent completes the questionnaire and consents.
• Apply disclosing agent to show plaque areas to the child (Figure 24).

Figure 24. Step of applying the disclosing agent at the first visit before the child brushes his teeth.

Figure 24. Step of applying the disclosing agent at the first visit before the child brushes his teeth.

Figure 25. (a-c). Steps of clinical part.

Figure 25. (a-c). Steps of clinical part.

Figure 26. Step of applying of disclosing agent at the first visit after the child brushes his teeth under supervision.

Figure 26. Step of applying of disclosing agent at the first visit after the child brushes his teeth under supervision.

• Examine plaque and gingival index using a diagnostic kit. Scores are based on the “Löe & Silness” modified dental plaque index [50].
• Plaque index: Scores range from zero to three based on plaque visibility and removal.
• Gingival index: Scores range from zero to three based on inflammation and bleeding.
• Demonstrate Fones’ circular tooth brushing technique using a dental demo [51].
• Provide a standard toothbrush and fluoride toothpaste, educating on proper toothpaste amount.
• Supervise child’s tooth brushing for two minutes (Figure 28a-c).
• Reapply disclosing agent to show brushing effectiveness (Figure 29).
• Record plaque index again.
• Install Go Go Brush app on parents’ phones and guide them on usage, especially the "Prove Yourself" section.
• Child watches the educational video twice.
• Child uses the app’s "Get Brushing" feature with camera filter (Figure 30).
• Instruct parents and child to use the app daily at bedtime until the next visit.
• Second Visit: One week after the first visit, the app rewards a new cap, confirming the child’s use. Record GI and PI, and schedule the third visit.
• Third Visit: After one month of using the app, record GI and PI, and parent completes the awareness questions.

Figure 27. The child trying the app's camera.

Figure 27. The child trying the app's camera.

• Control Group: Follow the same steps as the study group, excluding the mobile application usage. Evaluate plaque and gingival status at baseline, one week, and one month.

Questionnaire Part:

A self-administered questionnaire assesses mothers’ oral health knowledge and practices regarding their children. It consists of three parts.

• Demographic information.
• Practical questions.
• Awareness questions.

Translated into Arabic and reviewed for clarity, it is divided into sections for initial and follow-up assessments.

Practical Questions:

The second part includes seven questions about children's dental visits and brushing habits, such as whether they brush independently or with assistance and use fluoride toothpaste. It measures parental interest in their child's dental health.

Question "How often does your child have a dental visit?" has four response options, each assigned a specific score:

"Regularly every six months to once a year" = 3

• "Irregular" = 2
• "When there is a problem" = 1
• "Never" = 0

To assess sugar intake, we asked, "How many times does your child eat sugar a day?" with response options scored as follows:

• Three times a day = 0
• Twice a day = 1
• Once a day = 2
• Rarely = 3
• Not every day = 4

A question about brushing frequency scored as follows:

• Irregularly = 1
• Never cleaned = 0
• Once a day = 2
• More than once a day = 3

For mouth rinsing after sugary foods:

• Always = 3
• Frequently = 2
• Rarely = 1
• Never = 0

To gauge knowledge about fluoride toothpaste, we asked, "Do you use fluoridated toothpaste for your child?" with scores:

• Always = 3
• Most of the time = 2
• Sometimes = 1
• Never = 0
• I don't know = 0

Awareness Questions:

• The third part includes 15 questions assessing parents' knowledge about primary teeth care. Answers are "yes," "no," or "I don't know," scored as "1" for correct and "0" for incorrect answers. The app includes a "prove yourself" section with questions and explanations to promote awareness. Parents completed the questionnaire on the first and third visits.

3.3. Validity and Reliability

• The questionnaire translation was tested by five dental professionals and modified based on their feedback.
• A pilot study with 20 mothers at Mansoura University's pediatric dentistry clinics refined the questionnaire, achieving a coefficient of agreement of 90% and 92%.

3.4. Statistical Analysis

Data were analyzed using the Statistical Package of Social Science (SPSS) for Windows (Standard version 26). Normality was tested with a one-sample Kolmogorov-Smirnov test.

• Qualitative data were described using numbers and percentages and compared by McNemar test.
• Continuous variables were presented as mean ± SD for normally distributed data. Paired groups were compared with paired t-tests, different groups with Independent t-tests, and more than two groups with ANOVA. Repeated measures ANOVA was used for one group at different follow-up periods.
• Spearman correlation was used for continuous data and ordinal data.

Significance was set at p ≤0.05.

4. Results

The current work aimed to investigate the clinical effects of a newly developed, oral hygiene smartphone application. Table 2 and Table 3 show the demographic information of the control and study groups and the parents' data of the study group. The mean age of the pediatric patients in the studied groups was (4.98 ± 0.80) years, with a range from 4 to 6 years old. Males and females were (51.6%) and (48.4%) of the study sample, respectively. Most of the participants were from a moderate social class (37.2 %), followed by the good, excellent, and then the poor class (34.8%, 18.1% and 9.9 %, respectively). Mothers of the study group were (31.20 ± 4.40) years old on average. Most mothers and fathers were university- educated (38.5% and 45.9%, respectively).

Table 4 shows a practice score among the study group. After examining the parents' answers to the questionnaire and calculating their answers statistically, it turns out that (63.1%) have a poor practice score and (36.9%) have a good practice score. Since the sum of the points of all the questions is 20, according to the median we considered that those whose answers total points are 10 or less poor practice and those whose answers total points more than 10 are good practice. The mean practice score was (9.30±2.88).

Table 5 and (Figure 28) demonstrate the change in parental awareness before and after the intervention by the Go Go Brush application, based on the questionnaire questions. The Mc Nemar test was used to calculate the P value. Most of the answers to the questions exhibit a significant statistical difference between before and after the intervention. This shows a direct correlation with the awareness of the parents after the intervention.

However, we notice that a few questions did not show a statistically significant change. The question "Toothbrushing should be started following the eruption of the first primary teeth" is not statistically significant, as the percentage of correct answers did not increase statistically sufficiently before the intervention by (15.6%) and after the intervention by (76.2%).

We could additionally observe no sign of significant change in the question "The frequency of intake of sugary substances plays a more important role than the total amount consumption of sugar in caries development." The percentage of incorrect answers before and after the intervention did not reduce statistically significantly. It was (16.4%) before the intervention and dropped to (12.3%) thereafter.

There is also the question "Carious primary teeth need to be restored". The results did not show any significant statistical change in the answers. The percentage of people who answered it incorrectly before the intervention was (16.4%), and after the intervention it became (14.8%)

The mean score of awareness before the intervention by the Go Go Brush application was (7.34±2.30), and after that, it became (9.82±3.25), which indicates a significant increase before and after the intervention. This was done using a paired t-test.

Table 7 and (Figure 29) explain the mean plaque scores of the study and control groups at baseline and after one week and one month. The plaque index was evaluated for the study group across three stages. initially, before any intervention; then, after one week of utilizing the app; and finally, after one month of app usage. Similarly, for the control group, assessments were conducted across three stages. during the initial visit, after one week, and after one month of follow-up. We used the repeated measurement ANOVA test and compared the groups using the post hoc LSD test. The results demonstrate a significant change in the mean plaque index within the study group after one week and one month of intervention. The mean plaque index score decreased from 2.41±0.28 to 1.16±0.38 after one week and further decreased to 0.695±0.25 after one month. This reduction is notably greater than the change observed in the control group, where plaque decreased from 2.23±0.33 to 1.95±0.35 after one week, and to 1.78±0.37 after one month.

Table (7) and (Figure 30) explain the mean gingival scores of the study and control groups at baseline and after one week and one month. The Gingival index was measured in three stages: at the first visit before the intervention, at the second visit a week after using the app, and at the third visit a month later. The findings reveal a substantial alteration in the mean gingival index scores among participants in the study group following one week and one month of intervention. Initially recorded at 0.942±0.36, the mean gingival index score decreased to 0.615±0.23 after one week, and further declined to 0.325±0.2 after one month. This reduction significantly exceeded the observed changes in the control group during the follow-up visits.

We note in Table 8 that there is no significant statistical relationship between the practice and awareness score with the mother's age (Figure 31).

Figure 31. Association between mother’s age and practice, baseline awareness, and awareness after one month.

Figure 31. Association between mother’s age and practice, baseline awareness, and awareness after one month.

Figure 32. Scatter diagram for a negative correlation between practice score and plaque index score before intervention by the app.

Figure 32. Scatter diagram for a negative correlation between practice score and plaque index score before intervention by the app.

Figure 33. Scatter diagram for negative correlation between practice score and gingival score before intervention by the app.

Figure 33. Scatter diagram for negative correlation between practice score and gingival score before intervention by the app.

We discovered a negative correlation between the plaque index score before the intervention, and the gingival score before the intervention with the practice score. The better the practical score, the lower the plaque and gingival index of the children and vice versa (Table 9 Figure 35,36). We also noticed a positive correlation between the mother's and father's education and social status with the practice score. The higher the social status and education of the parents, the higher the practice score

When comparing the awareness score, the plaque score, and the gingival score before the intervention and after the intervention by the app, we found a significant negative correlation between the gingival score before the intervention with the awareness before the intervention, so the higher the awareness of the parents, the lower the gingival score (Table 10). We also discovered that parental educational level has a positive correlation with pre-intervention awareness. The higher the educational level of the parents, the greater their awareness. There were no statistically significant changes in awareness after the intervention with plaque Index, gingival index, and demographic data.

We observed a negative correlation exists between the plaque index score after one week and the mother's age; the older the mother, the lower the plaque index. There is also a negative correlation between the parents' social level and educational level and the plaque index of their children before and after the intervention for one week. Table 11 shows that the lower the plaque index, the higher the parents' socioeconomic and educational levels. Further it reveals that there is no association between educational and social levels on the plaque Index after one month of intervention.

The relationship between the gingival score and demographic data is shown in Table 12. We observed an inverse relationship between the mean gingival index score of the child after using the app for one week and the age of his mother. All children's mean gingival index scores before the intervention, one week after the intervention by the app, and one month after the intervention all showed a strong inverse connection with the social level. The higher the social level, the lower the gingival score, and vice versa.

The results revealed a negative association between the parent's educational level and the mean gingival index score before intervention and the mean gingival index score after one week. The gingival index score for their kids is higher the less educated the parents are (Table 12).

5. Discussion

5.1. Children's susceptibility to dental caries.

Children's susceptibility to dental caries is heightened by their lack of cooperation and challenges in maintaining regular oral hygiene. It's crucial to consider their motivation and physical abilities for consistent oral health practices [41]. Gamification incentivizes behaviors like tooth brushing and makes oral health education appealing to children [52]. Leveraging modern technology, mobile learning with gamified applications can offer accessible and engaging health information [53]. These games, enriched with multimedia and interactive elements, align with children's digital native status, creatively conveying oral health information [54, 55]. However, there's a scarcity of application-based games for preschoolers focused on dental health education [56, 57].

5.2. Development of the gamification application.

This study is the first to create a gamified mobile application encouraging proper oral hygiene in children and promoting awareness among parents, supporting the Arabic language. The application combines gamification rewards and knowledge targeted at both the mother and child. The data was developed and revised under professional guidance.

5.3. Impact measurement.

To measure the app's impact on children's oral hygiene and mothers' knowledge, researchers followed participants for three visits over one month, similar to Desai et al., Zolfaghari et al., and Marchetti et al. [2, 9, 58]. Other research on toothbrushing ranged from a week to a year [4, 41-43].

5.4. Choice of platform.

The app was created for Android, chosen over iPhone due to affordability for the target middle or lower-class sample. Unlike Herrera et al.'s [59] iPhone-only app, this study's app is more inclusive, similar to Alkilzy et al.'s [43] research which used both Android and iOS.

5.5. Reminder notifications.

Effective health education should increase knowledge, foster a positive attitude, and promote behavioral changes. External motivators, like notifications, can enhance behavioral change. The Go GoBrush app sends reminders to parents at 9.00 PM, aligning with Zulfaghari et al.'s [9] study. Notifications at bedtime remind parents to brush their children's teeth, aligning with the optimal brushing time before bed [60, 61].

5.6. Effectiveness in orthodontic patients.

Studies like Alkadhi et al. [62] found mobile apps more effective than verbal instructions for children with fixed orthodontic treatment, leading to lower plaque and gingival index scores. Other studies also support the efficacy of mobile educational applications in improving oral health in adolescents with fixed orthodontics [17, 63].

5.7. Correlation with demographics.

An inverse correlation was observed between plaque and gingival index scores after one week of intervention and mothers' age in the study group. Higher social and educational levels of parents also correlated with lower scores, similar to findings by Bashirian et al. [64]. After one month, no significant correlation was found, suggesting the app's impact is independent of demographic factors. This aligns with findings by Spetz et al. [18], which showed mobile educational applications benefited children's preventative and restorative care.

6. Conclusions

Oral hygiene is essential for preventing dental caries, yet many preschool children struggle to maintain good practices due to insufficient support from parents and dentists, finding tooth brushing tedious. This study aimed to develop a gamified mobile app, Go Go Brush, targeting Arab preschoolers to improve their oral health and increase parental knowledge. The study involved 122 children in the study group and 50 in the control group, with initial questionnaires, toothbrushes, and oral hygiene education provided. Plaque and gingival indices were measured using training-assisted brushing with a disclosing agent. The Go Go Brush app, downloadable on Android, included a plaque removal video. Effectiveness was assessed through changes in plaque and gingival indices at one week and one month, along with a usability evaluation. Results showed significant improvements in plaque and gingival indices in the study group after one month, with plaque scores dropping from 2.41±0.28 to 0.695±0.25 (p<0.001) and gingival scores from 0.942±0.36 to 0.325±0.2 (p<0.001). Parental awareness also increased. Thus, the Go Go Brush app demonstrates potential in enhancing oral health among preschoolers and raising parental awareness, underscoring the effectiveness of technology-assisted dental care interventions in early childhood.