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

A controlled trial to compare the ability of foam swabs and

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

and Jane Luise Hutton BSc DipMathStat PhD DIC CStat

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

Submitted for publication 13 July 2001

Accepted for publication 31 May 2002

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

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

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

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2002 Blackwell Science Ltd

Issues and innovations in nursing practice
Introduction
Mouthcare is a concept familiar to nurses and is a term used
to embrace the care given in a variety of situations that
require decisions to be made about what tools and actions are
likely to achieve the best outcome for patients or clients with
the minimum of risk (Trenter Roth & Creason 1986,
Griffiths & Boyle 1993, Kite & Pearson 1995, Pearson &
Chin 1997). One tool commonly employed in mouthcare is
the foam swab.
Foam swabs have been used in the United Kingdom (UK)
since the early 1970s, and, despite repeated and long-standing
efforts to improve the practice of mouthcare given by nurses
(e.g. DeWalt & Haines 1969, Wiley 1969, DeWalt 1975,
Howarth 1975, 1977, Harris 1980, Lewis 1984, Trenter
Roth & Creason 1986, Hunt 1987, Miller & Rubinstein
1987, Pritchard & Mallet 1992, Clarke 1993), they are
frequently used in practice today. This may be in part due to a
lack of robust information about what it is that foam swabs
can bring to quality nursing practice, and to the lack of
emphasis in education and practice on the assessment of
mouthcare needs, and delivery of effective care (Adams
1996).
The evidence-based practice movement of the 1990s
(Kitson 1997) and current emphasis on the need to identify
and use effective interventions in health care in the UK
requires that we look more carefully at what we do, and
for evidence to support decision-making wherever possible
(Closs 1997). Although mouthcare is a complex concept
which uses knowledge from a variety of sources (Carper
1978), it does use
empirical or
scientific knowledge that can
and should be collected systematically. This knowledge can
then underpin and inform decisions made in the context of
planning and delivering care.
Evidence for the ability of foam swabs to clean tooth
surfaces by removing dental plaque from tooth surfaces is
limited. Studies that seek such evidence need to use methods
that make plaque visible to the naked eye, and to quantify the
amount of plaque visible. These factors make practice-based
studies difficult and potentially unethical, and may have
contributed to the lack of robust studies in the area. One
study frequently quoted as evidence for foam swabs being
ineffective at removing plaque is that of DeWalt (1975). Here
plaque accumulations were quantified on volunteers using
the scoring procedure of Greene and Vermillion (1960). The
amount of plaque on tooth surfaces was estimated after using
a plaque disclosing solution and was recorded as the area of
each tooth covered.
More recent findings relating to the role of plaque in the
onset and progression of gingivitis in humans highlight the

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Plaque removal capability of mouthcare tools
importance of plaque that accumulates along and below the
gingival margin (Levine 1989) and so it is important
that future studies quantify this plaque. Plaque allowed to
accumulate in this area is reported to cause tissue changes
within 2–4 days (Page & Schroeder 1976) and will result in
clinically apparent gingivitis within 7–21 days (Löe et al.
1965, Theilade et al. 1966).
Toothbrushing is a very common means of plaque removal
in Western populations, although it is not always effective
and can result in problems if not used correctly (Addy et al.
1992). The effect of different kinds of toothbrush on plaque
removal and gingival health is an ongoing focus in dental
research where clinical trials to compare the effect of different
tools on a variety of oral indices are common (Bastiaan 1984,
1986, Gibson et al. 1986, Killoy et al. 1989, Agerholm
1991).
An earlier series of experiments completed in the mouths of
two people to compare the effect of a toothbrush and foam
swabs on plaque accumulation and removal (Pearson 1996)
have suggested that toothbrushes could remove plaque from
the sites studied if used effectively and that foam swabs
could not remove plaque which had accumulated in
shel-
tered areas on or between teeth. These findings could inform
decision-making by educators with a responsibility for skill
development and clinical practice if they were found to be
generalisable to a wider population, i.e. effective toothbrush-
ing skills would enhance care, and foam swabs would not be
a tool of choice when care aimed to remove dental plaque.
This paper is a report of a clinical trial, which sought to
measure how effective foam swabs are at removing dental
plaque, when compared with a toothbrush.
The study
Research questions
The research questions addressed by the study are:
• Is there a difference between the ability of foam swabs and
a toothbrush to remove dental plaque from approximal
and crevice surfaces?
And, if there is a difference,
• What is the magnitude of the difference between the ability
of foam swabs and a toothbrush to remove dental plaque
from approximal and crevice surfaces?
Method
The method used to report this trial was guided by the
proposals of The Standards of Reporting Trials Group
(1994). Oakley (1990) describes the origins and limitations
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L.S. Pearson and J.L. Hutton
of the randomized control trial as a means of generating
information for use in situations where people are the focus
of the trial. This study uses the method as a means for
generating information that can then be applied carefully to
the practice situation.
Preparation for the study
The plaque scoring system used previously (Pearson 1996)
and described in Fig. 1 was used to quantify plaque that had
accumulated along the gingival crevice and approximal
buccal surfaces (see Figure 3) of the upper and lower four
teeth either side of the mid-line. These surfaces were chosen
because they are easily accessible to the tools used in the
trial, i.e. a toothbrush and foam swab, and easily seen by
the scorer. Therefore they represent what might be consid-
ered the
best performance areas for both tools. Measure-
ment of plaque was practised by the scorer, and accuracy of
recording checked through the process of two researchers
comparing scores for disclosed plaque collections on buccal
surfaces of teeth in photographs and on each others teeth.
Ethical approval and recruitment of participants
Issues relating to the study design and purpose, methods of
recruitment and feedback to participants, and data collection
methods were all subjected to the scrutiny of a departmental
ethics committee, which then gave approval for the work to
proceed.
Volunteers were recruited to the study through a depart-
mental open seminar which addressed the scientific basis for
nurse-administered mouthcare; personal invitation; respond-
ing to a call for participants via departmental notice boards;
and by personal referral after talking to people who had
already taken part in the study. Preliminary findings of the
study were reported back to participants.
The nature of, and need for, such a study was explained to
all potential participants prior to being recruited. People who
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2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
did not have their upper and lower eight front teeth were
excluded from the study. Those who had dental caps on teeth
were advised that the plaque disclosing tablets (Boots Com-
pany Limited, Nottingham, UK) might initially leave a residual
stain on these teeth and that this stain would fade after
successive cleaning of the teeth. The decision regarding
whether to be included in the study was then left to individuals.
Protocol
The protocol used for the study is given in Fig. 2. Thirty-four
volunteers (mainly staff and students) took part in the
trial, which involved attending two 30-minute appointments
1 week apart (Week one – Appointment 1, and Week 2 –
Appointment 2 in Fig. 2). Participants refrained from their
usual toothbrushing practice on the morning of each
appointment and had the plaque on the buccal surface of
the upper and lower front eight teeth (four either side of the
midline) disclosed and scored. This score represented the

Baseline before treatment scores in Fig. 2. The plaque scorer
wore a fresh disposable latex rubber glove on the hand used
to uncover the teeth under investigation during the plaque
scoring procedure. This procedure took place in the same
geographical location throughout the study and used natural
light supplemented with light from a reading lamp if the
former was not adequate.
Participants were then allocated to one of two groups
(Group A & Group B) using alternate allocation in order to
ensure that group sizes were kept the same. Randomization
of individuals was not essential because each person acted as
their own control. Each group then proceeded through its
own order of treatments, which were reversed in the second
week. This reversal of the order of treatments was included in
the design of the study to ensure that any learning effect
resulting from the order of treatments (toothbrushing or
using foam swabs) could be assessed.
Figure 1 Plaque scoring system.
Issues and innovations in nursing practice
Figure 2 Protocol used for study.
In week 1, Group A people used a toothbrush first, had
their plaque scored, and then used a foam swab before having
their plaque scored again (final score for week 1). In week 2
these people used a foam swab first, had their plaque scored,
and then used a toothbrush before having their plaque scored
for a final time (final score for week 2).
In week 1 Group B people used a foam swab as the first
treatment, had their plaque scored, and then used a toothbrush
before having their plaque scored again (final plaque score for
week 1). In week 2 these people used a toothbrush first, had
their plaque scored, and then used a foam swab before having
their plaque scored for the final time (final score for week 2).
Participants were given feedback about any residual plaque
at the end of the scoring procedure in week 2 and methods
which might ensure total plaque removal during their normal
toothbrushing procedure. Further referral for advice about
aspects of mouth care were offered and discussions of issues
which had been highlighted by the study occurred in groups
and in one-to-one settings.
Treatments
Toothbrushes were supplied by Johnson and Johnson Patient
Care Limited, Ascot, UK. When using a toothbrush, partici-

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Plaque removal capability of mouthcare tools
pants were asked to clean their teeth using their normal
toothbrushing procedure but without using a mirror. When
using a swab, they were instructed to use a swabbing tech-
nique, i.e. to moisten the swab with tap water and to wipe
it horizontally across all the teeth in the experimental area
in both directions, concentrating the action on the tooth-
gingival margin under investigation. This was to mimic the
attention that the sites under investigation might receive
during mouthcare in a clinical situation.
Data collection
Data were recorded for plaque in the gingival crevice and
approximal sites (Fig. 3) for each of the eight upper and eight
lower teeth under investigation in each person at each stage
of the study. Each tooth has two approximal surfaces and
one crevice surface. The total number of plaque accumula-
tion sites studied was 1632, made up of 816 upper and 816
lower sites, of which 1088 were approximal and 544 were
crevice sites.
Data were entered into the MINITAB statistical analysis
package in a form that enabled the research questions to be
addressed.
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L.S. Pearson and J.L. Hutton
Teeth from above
Smooth surface Approximal
plaque plaque
Teeth from the side
Supra-gingival
plaque
Sub-gingival
plaque
Gum margin
Results
The study was designed to assess whether there is a difference
between the ability of a foam swab and a toothbrush to
remove dental plaque from surfaces of the teeth; from
different surfaces of teeth (viz approximal and crevice); and
from different places in the mouth (viz upper vs. lower and
left vs. right). A further aim was to quantify any differences
found.
Descriptive statistics, contingency tables, analysis of vari-
ance (ANOVA ) and paired t-tests were used to analyse the data
after checking the distribution of the scores. Non-significant
higher order interactions were eliminated before the main
effects of treatments were assessed. Although the initial
plaque scores were ordinal, the significance tests used
were based on the normal distribution. The scores used in
the statistical tests were average scores for each person, for
example over 32 sites for approximal surfaces or 16 sites
for crevice surfaces. The legitimacy of the use of the normal
distribution was confirmed by histograms of these mean
plaque scores: this was as expected from the central
limit theorem (Armitage 1971).
No significant difference is
used when P > 0Æ2 (not even marginal evidence for these
differences).
In order for the research questions to be answered it was
important to ensure that the baseline data for weeks 1 and 2
(starting plaque scores) were similar (not statistically differ-
ent) and that there had been no
carry over/historical learning
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2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Fissure
plaque
Gingival crevice Figure 3 Plaque accumulation sites (taken
plaque from Pearson 1996).
effect from week 1 to week 2. This was achieved by seeing if
there was any significant difference between the sets of data
outlined above at the beginning of each experiment, and after
similar treatments across the weeks.
Analysis of variance of the baseline data showed that there
was no significant difference (P > 0Æ2) between plaque
scores for individuals and groups for weeks one and two
(see Table 1). This was the case for total plaque scores, upper
and lower plaque scores, left and right sides, approximal and
crevice plaque scores. Therefore there was no statistically
significant difference between groups A and B baseline data
and no measurable effect of the individuals being in the trial.
In addition, there was no significant difference (P > 0Æ2)
between the final data (plaque scores after treatment 2) and
data produced as a result of the order of the treatments
between the groups and weeks (toothbrushing or swabbing
as a first treatment, regardless of which week it occurred in).
Analysis of variance of the differences between scores after
swabbing and after brushing indicated no difference
between upper and lower, or left and right sides. These
factors can therefore be eliminated by taking their averages
over them.
Summary statistics
The consequences of the similarities in baseline and final data
for the two groups and weeks means that we can be confident
the changes in plaque scores after treatments are best
Issues and innovations in nursing practice Plaque removal capability of mouthcare tools

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

Mean SD Minimum Maximum

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

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

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

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

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

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

6
Stage measurement taken

0 1 2

Mean plaque score

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

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489 485
L.S. Pearson and J.L. Hutton
5
Stage measurement taken
0 1
Mean plaque score
1 – Before; 2 – After brush first; 3 – After swab second;
4 – Before; 5 – After swab first; 6 – After brush second.
Table 2 demonstrates the difference in effectiveness
between toothbrushing and swabbing for crevice and
approximal sites. The average mean score for approximal
sites with a toothbrush is 0Æ77 less than the mean score after
using a swab (P ¼ 0Æ001). This means, approximately, that
there are 77% more clean approximal sites after using a
toothbrush than there are after using a swab.
The average mean score for crevice sites with a toothbrush
is 0Æ44 less than the mean score after using a swab (P ¼
0Æ001). This means, approximately, that there are 44%
more clean crevice sites after using a toothbrush than there
are after using a swab.
Discussion
Critique of the study design
The consequences of the similarities throughout the data set
described above means that there were no problems with
using alternative allocation of participants to groups. Ran-
dom allocation would have been preferable. Alternative
allocation was more convenient, and the lack of period
and carry-over effects shows that it is effective for this
evaluation.
The direction of differences between the effectiveness of
swabs and toothbrushes uncovered in this trial is unlikely to
be different after replication with a sample from a similar
population group, or if the sample size were increased. The
486
2
Figure 5 Boxplots of mean scores on
approximal surfaces by treatments.
majority of plaque that was present on teeth in this study
was relatively new and nonadherent because most of it was
removeable by using a toothbrush properly. However, the
nature of the baseline data may not be the same if it were
ethical to repeat the study with an actual patient/client
group. Initial plaque levels may well be higher in some
groups and in some people there may be accumulations of
mature plaque calcified on tooth surfaces which are not
removable with foam swabs or toothbrushes. Certainly the
impact of using foam swabs on such plaque would be
minimal, less than on newer plaque, and less than if a
toothbrush were used.
The tooth surfaces chosen in this study represented those
that are easily seen and scored for plaque, and which are most
accessible to either of the tools. As such they almost represent
a laboratory setting where the tools are given the best chance
of working, and where errors in scoring of plaque are
minimized. The plaque removing capabilities of the tools in
different areas of the mouth may vary, but again, toothbru-
shes will perform better than swabs.
In this study the
mouthcare was delivered by each person
themselves, and the effect of this could well be different than
if the care was delivered by someone else, for example, a
nurse delivering mouthcare. The direction of the difference
would depend on a number of factors, e.g. the dexterity of the
person doing the mouthcare (self or other), the accessibility of
the tooth surfaces. Pooling of the plaque score data for
analysis purposes means that the range of effects of the tools

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Issues and innovations in nursing practice
Figure 6 Example of a completed data collection tool.
on plaque in the mouths of individual cases is lost. This
emphasizes the importance of feedback to individuals who
took part in the study.
Finally, the actual techniques for swabbing and tooth-
brushing were only partially standardized. However, the
magnitude and direction of the differences in the performance
of the two tools is such that this is very unlikely to have had a
significant effect on the performance of each.

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Plaque removal capability of mouthcare tools
Application to nursing practice
The results of this trial need careful application to nursing
practice. Choice of mouthcare tools takes place within
the complexities of care. Local issues known to individual
practitioners and patients/clients need consideration and risk
assessment where appropriate. These might include patient
preference and informed choice, the aims of each mouthcare
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L.S. Pearson and J.L. Hutton
Table 2 Demonstrating the difference in effectiveness between
toothbrush and swab for crevice and approximal sites
Means for mean scores by
crevice and approximal sites
Crevice Approximal
Baseline to after brush score 0Æ99 0Æ94
Baseline to after swab score 0Æ55 0Æ17
Difference in means (effectiveness) 0Æ44 0Æ77
t-statistic 16 22
P-value 0Æ0001 0Æ0001
intervention, potential risks of poor plaque removal, the likely
duration of nurse administered plaque removal, the knowledge
base and skills of people performing care, and the economics
and politics of staff development (Pearson 1996). However, if
we focus on the kernel issue of this trial, that is plaque removal
as an adjunct to dental health, we can say that the effective use
of a toothbrush will be substantially more effective at removing
dental plaque than the use of foam swabs.
Conclusion
This trial sought to measure how effective foam swabs are at
removing dental plaque, when compared with the effect of
using a toothbrush. Earlier experiments had suggested that
toothbrushes could remove plaque from the sites studied if
used effectively, and that foam swabs could not remove
plaque which had accumulated in
sheltered areas on or
between teeth. This trial verified these findings in a larger
sample and it is argued that the findings can be generalized to
a wider population because of the magnitude and direction
of the differences measured. The size of the difference in
performance of the tools can only be used in relation to this
study and should not be quoted as a measure of the differences
of the abilities of the tools to remove plaque from tooth sur-
faces in general. The findings do have implications for nurse
education and the development of nursing in practice
settings. These include the need to teach effective tooth-
brushing skills to nurses so that they can be used in situations
where teeth must be cleaned on behalf of patients. This may
require the input of dental hygienists to teaching pro-
grammes. Staff need to be supported in developing mouthcare
practice, especially in the development and use of assessment
strategies that include the choice of effective tools.
Acknowledgements
Thanks to all those who participated in the trial, to Rachel
Tucker (Research Assistant at the then Institute of Nursing
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2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 480–489
Studies in Hull University) who administered the trial and
collected plaque accumulation data, and to Johnson and
Johnson Patient Care Limited, Ascot, for supplying us with
toothbrushes for the trial.
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