MED. INFORM. DECEMBER
                    (                 2003)     VOL.   28,  NO.   4, 291­298




Development of Web-based intervention system for
periodontal health: a pilot study in the workplace

               MIKI OJIMA{*, TAKASHI HANIOKA{, MASAE KUBONIWA{,
               HIDEKI NAGATA{ and SATOSHI SHIZUKUISHI{
               {Department of Preventive Dentistry, Graduate School of Dentistry,
               Osaka University, 1-8 Yamadaoka, Suita, Osaka, 565-0871, Japan
               {Department of Preventive and Public Health Dentistry, Fukuoka
               Dental College, Tamura 2-15-1, Sawara-ku, Fukuoka, 814-0193, Japan


               (Received February 2003)


               Abstract. Background: It has recently been accepted that periodontal disease is a risk
               factor for not only tooth loss but also systemic diseases. An effective system of public
               intervention for periodontal health to enable continuous intervention of dental
               professionals has been sought. We developed a Web-based intervention system
               regarding periodontal health and evaluated the effects of the system in the workplace.
               Methods: The system was capable of storage and display of personalized oral health
               records including video images pertaining to toothbrush manipulation within their own
               oral cavities based on instructions by dental professionals. The system enabled clients
               to view movement of their own skill, and repeatedly. Thirteen workers of a company
               were randomized to either an experimental or control group. The control group
               received face-to-face toothbrushing instruction at the company and follow-up via
               telephone. The experimental group received follow-up through our system in addition
               to those components employed in the control group.
               Main results: The workers in the experimental group benefited in terms of improvements
               of not only plaque removal but also periodontal health over 3 months.
               Conclusions: These results indicate that implementation of an Web-based approach for
               periodontal health affords the possibility of remote instruction and produces additional
               public benefit.


               Keywords: WWW; Periodontal health; Intervention; Teledentistry.



1. Introduction
   Prevalence of periodontal disease is high regardless of age or sex throughout the
world [1]. It has recently been accepted that periodontal disease is a risk factor for
not only tooth loss but also systemic diseases [2]. Appropriate oral self- and profes-
sional-care are necessary for prevention of periodontal disease [3]. Toothbrushing,
which is the simplest oral self-care method, is essential to maintain health of teeth
and gingiva; however, many people practice poor brushing techniques. One-off in-
struction and education regarding toothbrush use by dental professionals are prac-
ticed in the workplace or within communities in Japan. However, the system is not
sufficient to change people's behaviour regarding oral self-care due to the transient
attention focused on periodontal health during receipt of oral health instruction [4].
In addition, follow-up in the workplace or in communities requires much time and
high cost. Therefore, a more effective system of public intervention to enable con-
tinuous intervention of dental professionals has been sought.


*Author for correspondence; e-mail: ojima@dent.osaka-u.ac.jp

  Medical Informatics & The Internet in Medicine ISSN 1463-9238 print/ISSN 1464-5238 online # 2003 Taylor and Francis Ltd
                                                http://www.tandf.co.uk/journals
                                             DOI: 10.1080/14639230310001617823

292                                            M. Ojima et al.


    The Internet is rapidly becoming available to the public. More importantly, the
Web has become a standardized infrastructure providing access to sophisticated
telemedicine applications from virtually any machine and operating system [5].
Several experiments related to Web-based intervention were conducted in the
medical field [6, 7]. Recently, the Web has emerged as a platform for computer-
based oral health records [8]. To the best of our knowledge, although no reports
have been published concerning a Web-based intervention system for periodontal
health, the technology could also apply to the continuation of toothbrushing in-
struction. In the present study, a novel intervention system for periodontal health
was developed based on Web technology. In addition, a pilot study was conducted
in the workplace to evaluate the effect of the system in terms of intervention.



2. Methods
2.1. System design
    Requirements for the success of chronic disease management intervention in-
clude: (1) efficient collection and use of data for personalization, (2) active involve-
ment of patients and (3) follow-up phone contacts [9, 10]. We considered these
requirements in relation to characteristics of the Web, such as multimedia, inter-
active user interface and telecommunications. Figure 1 exhibits the basic concept
of this system. A Web server was activated at the Graduate School of Dentistry,
Osaka University. The server executes a common gateway interface (CGI) pro-
gram written in Perl, version 5.004. Minimal requirements for the use of this sys-
tem are access to the Internet and an ordinary Web browser.




                                     Dental staffs
                                        Dentists
                                         Dental hygienists



                           Accesses for follow-up intervention to each clients           Home

                                                                           Clients


    Osaka Univ.                  Accesses for repeated learning of brushing method


                                                                          Clients

    Web server                                                                          Workplace

 Oral health record
 . Text(patient-specific advices)                                 Face-to-face toothbrushing instruction by dental staff
 . Image(patient tooth alignment)                                 Capturing of personalized information for each clients
 . Videoclips (toothbrush manipulation)                           at the instruction




                                   Figure 1. Basic concept of the system.

                   Web-based intervention system for periodontal health                            293


    The system is capable of storage and display of personalized oral health records
based on instructions by dental staff. In order to create effective intervention [11],
materials for oral self-care were tailored to each individual. The material contained
three types of files: a text file, an image file and video files. Patient- specific advice
based on instruction was written in the text file. The image file documents patient
tooth alignment and indicates locations where patients should exercise greater cau-
tion. The video images demonstrated toothbrush use in areas that are difficult to
clean. Two types of video formats were prepared: Quicktime for mainly Macintosh
computers and Audio Video Interleaved (AVI) formats for mainly Windows. CGI
program dynamically built and displayed a hypertext markup language (HTML)
file based on the above files when it was executed. Figure 2 shows an example of
the HTML page based on oral health record. Items based on instruction were
listed in the table enabling clients to check their behaviours or brushing methods.
Important items were also graphically displayed. Several items concerning tooth-
brush movements were hot links to the video images, which were recorded at work-
place examination. When clients receive re-instruction, a new component for
check-up will be added to the page.
    Users were authenticated through a combination of identification code (ID) and
password upon logging into the system. Authentication rules were embedded with-
in a CGI program. Following successful log-in, dental staff were provided a list of




Figure 2. Presentation of an example of HTML page based on the oral health record. The record
      consists of text, picture and video files. The personalized information contains patient-specific
      advices (left of the large window), their tooth alignment (right of the large window) and suitable
      brushing methods (two small windows). This page was originally written in Japanese. The URL
      is an English page for the demonstration is http://pinocchio.dent.osaka-u.ac.jp/ojima/occup/
      index-ed.html.

294                                 M. Ojima et al.


clients assigned to him or her shown on the Web page. To view the record of any
client, the dental staff clicked on any one of the hyperlinked patient names on the
list. Clients could view only their record following log-in. Clients could access their
oral health records on the Web server from their home and workplace. Clients
could repeatedly learn effective brushing methods without restrictions in terms
of location or time.


2.2. Experimental implementation of the system
    Thirteen workers were randomly assigned to two groups: Control (group C)
(n = 7) or Experimental (group E) (n = 6). The workers were familiar with Internet
access. The subjects in the group E were not trained for use of the system. No dif-
ferences in the mean age and sex ratio were found between the two groups. Sub-
jects in the study did not have severe systemic disease and receive any
periodontal and antibiotics therapy during the examination. Figure 3 depicts the
schedule of intervention. Intervention for workers in group C consisted of two oc-
casions of face-to-face toothbrushing instruction and telephone follow-up. The
baseline intervention consisted of initial face-to-face instruction conducted by den-
tal hygienists at the workplace for 15 ­ 20 min. Toothbrushing instruction included
cleaning of teeth and gums with toothbrushes and plaque disclosure. Three weeks
after the baseline examination, the second instructional meeting was conducted by
dental hygienists at the workplace. The instruction consisted of a revision and con-
firmation of the first instruction. Two months after the baseline, the dental hygie-
nists conducted follow-up by telephone to encourage each worker. Personalized
information from each worker captured by dental hygienist at the instruction were
converted a text file, an image file and video files, and stored in the Web server.
Workers in group E received Web-based follow-up via our system in addition to
that intervention described for clients in group C. Assessments of periodontal
health with indices of periodontal destruction and gingival inflammation [12],
and plaque removal with indices of plaque accumulation [13] and oral hygiene
[14] were conducted at the baseline and at 3 months following the initial examina-
tion. Video images for each person were acquired with a digital video camera




  group C


   First intervention    Second intervention         Third intervention

     First instruction   Second instruction                Telephone
     Taking video images                                                Access to our system


  group E



        Examination                                                               Examination


          Baseline       3 W                                 2 M                        3 M

                       Figure 3. Schedule of intervention in this study.

                               Web-based intervention system for periodontal health                     295


(DCR-TRV10, Sony Co. Tokyo, Japan) at the time of baseline instruction. All
workers, following explanation regarding the objective and use of the video images,
provided informed consent.


2.3. Statistical analysis
                    Reduction rate of clinical parameters was calculated as ([measurements at base-
line] ­ [measurements at 3 months after]/[[measurements at baseline] 6 100. Dif-
ferences with respect to reduction rate of clinical parameters were verified in
each group at baseline examination and at 3 months after the baseline examination
utilizing Wilcoxson test in order to evaluate the effect of Web-based intervention.
These analyses were performed with the StatView Ver 4.5 statistical package
(Abacus Concepts, Inc., CA, USA). The level of significance was set at 5%.



3. Results
3.1. Results of implementation
                    During the 1-month experimental period, the system received 33 total requests
(5.5 requests per individual on average). The greatest number of requests per in-
dividual was seven. Approximately 75% of requests were received in the first 3 days
of the experimental period. The time period characterized by the highest frequency
of requests was noon to 6 pm.


3.2. Changes in clinical parameters during the 3-month period
                    Figure 4 displays the mean reduction rate of clinical parameters in groups C
and E during the 3-month post-baseline examination. Differences in indices of



                                                                                    group E         group C


                     100                            *


    (%)               80                                    *            *


       rate           60      *                                                                 *      *


                      40


                      20
           Reduction

                       0
                             Periodontal           Plaque               Gingival                   Oral
                             inflammation          accumulation         inflammation               hygiene

Figure 4. Reduction rate of all clinical parameters during the 3-month period. *Significantly different
                          between the baseline and the 3-month examination in the group (p 5 0.05).

296                               M. Ojima et al.


periodontal destruction, plaque accumulation, gingival inflammation and oral hy-
giene between the baseline and the 3-month examination were significant in group
E (p = 0.046, 0.027, 0.028 and 0.028, respectively), whereas in group C, only differ-
ences in indices of plaque accumulation and oral hygiene were significant (p = 0.026
and 0.018, respectively).


3.3. User's comments after the system trial
   The following comments were obtained from workers of group E in a question-
naire conducted after the trial: (1) I think that this system is useful for checking
how to brush my gums later without restrictions in place and time. (2) I hope
the system will have greater interactive user interface. (3) Functions using audio
will make the instruction on the Web more effective.



4. Conclusions
4.1. Use of the system
   Workers accessed their tailored records on the Web approximately five times on
average; most requests occurred in the first 3 days. These findings indicate that
workers utilize the on-line service to review suitable brushing methods. Thus,
an Internet-based system could allow remote support by dental professionals.
The system may also compensate for the lack of instruction time. However, since
users easily tend to lose interest in the materials, additional interactive functions
should be added to the system in order to appeal to users continuously and to make
the follow-up more effective.


4.2. Effect of Web-based intervention
   Improvement in plaque removal was observed in group C during the 3-month
period. This finding agrees with the report regarding the effectiveness of re-in-
struction with respect to improvement of plaque removal compared to one-off in-
struction [15]. Intervention applied in group E included a Web-based follow-up in
addition to those components in group C. Intervention was effective in terms of
improvement not only in indices of plaque accumulation and oral hygiene (plaque
removal) but also in indices of gingival inflammation and periodontal destruction
(periodontal health). These results indicate that the Web-based approach is more
effective than conventional intervention. Further studies should consider longer-
term and behavioural effects on periodontal health using the Web-based interven-
tion.


4.3. Utility of video images
   A simple and efficient manner by which to improve plaque removal in-
volves provision of educational materials related to toothbrushing instruction.
Video images have the advantage of depicting movements of a brush on the
gums and teeth; as a result, this instruction provided an additional benefit to
written instruction [16]. Video images available in this study presented the ac-
tual movements of toothbrushing taught by the dental hygienist. In addition,
the system was designed such that workers could refer to images on the
Web. Repeated viewing of images pertaining to toothbrush manipulation within
their own oral cavities could motivate clients to change their brushing beha-
viour.

                     Web-based intervention system for periodontal health                             297


4.4. Limitation of study and future overview
    Implementation was conducted at a small company; consequently, the number
of subjects was limited in the present investigation. Therefore, we are now plan-
ning a longitudinal follow-up study involving a larger population. The outcome
of this study could serve an evidence of the effectiveness of Web-based interven-
tion and support the future work for the application to the public.
    Increasing interest exists regarding public health intervention involving low-
cost, self-help materials and minimal support from professionals [17]. Teledentis-
try, which is a new field in dentistry, possesses the two advantages of improvement
in accessibility of health care and reduced health care costs [18]. A Web-based in-
tervention system for periodontal health may serve as a novel concrete example of
teledentistry.
    The experimental implementation of our system suggested that the Internet,
especially the Web, could provide the public with health information, as well as
effective intervention. The Web is a low-cost multimedia technology and is avail-
able as a telecommunication tool [8]; consequently, the system may enable the crea-
tion of supportive environments and the strengthening of community action for
oral health promotion in ways that few other innovations have. Information tech-
nology, which can function as a communication builder for dental researchers or
practitioners, also has the potential for providing the public with better health ser-
vices.



Acknowledgement
    The authors thank Kiyoharu Iwata, Jyunko Hashimoto (Association for
Preventive Medicine of Japan) and Ryoichi Matsuse (Kyoto Medical Science
Laboratory Inc.) for assistance with the implementation of the system, and Dr.
Hiroo Tamagawa (Osaka University Dental Hospital) for his helpful comments.



References
 1. http://www.dent.niigata-u.ac.jp/prevent/perio/contents.html.
 2. SCANNAPIECO, F.A., 1998, Position paper of the American Academy of Periodontology: periodontal
    disease as a potential risk factor for systemic diseases. Journal of Periodontology, 69, 841 ­ 850.
 3. US PREVENTIVE SERVICES TASK FORCE, 1997, Guide to Clinical Preventive Services, 2nd edn
    (McLean:International Medical Publishing, Inc.)
 4. AINAMO, J. and AINAMO, A., 1996, Risk assessment of recurrence of disease during supportive per-
    iodontal care. Epidemiological considerations. Journal of Clinical Periodontology, 23, 232 ­ 239.
 5. BELLAZZI, R., MONTANI, S., RIVA, A. and STEFANELLI, M., 2001, Web-based telemedicine systems
    for home-care: technical issues and experiences. Computer Methods and Programs in Biomedicine, 64,
    175 ­ 187.
 6. OENEMA, A., BRUG, J. and LECHNER, L., 2001, Web-based tailored nutrition education: results of a
    randomized controlled trial. Health Education Research, 16, 647 ­ 660.
 7. STARREN, J., HRIPCSAK, G., SENGUPTA, S., ABBRUSCATO, C.R., KNUDSON, P.E., WEINSTOCK,
    R.S. and SHEA, S., 2002, Columbia University's Informatics for Diabetes Education and Teleme-
    dicine (IDEATel) project: technical implementation. Journal of American Medical Informatics As-
    sociation, 9, 25 ­ 36.
 8. SCHLEYER, T.K. and DASARI, D.R., 1999, Computer-based oral health records on the World Wide
    Web. Quintessence International, 30, 451 ­ 460.
 9. CLARK, N.M., BECKER, M.H., LORIG, K., RAKOWSKI, W. and ANDERSON, L., 1991, Self-manage-
    ment of chronic disease by older adults: a review and questions for research. Journal of Aging
    Health, 3, 3 ­ 27.
10. WASSON, J., GAUDETTE, C., WHALEY, F., SAUVIGNE, A., BARIBEAUN, P. and WELCH, H.G., 1992,
    Telephone care as a substitute for routine clinic follow-up. Journal of American Medical Association,
    267, 1788 ­ 1793.

298                                         M. Ojima et al.

11. BROWN, S.J., LIEBERMAN, D.A., GERMENY, B.A., FAN, Y.C., WILSON, D.M. and PASTA, D.J.,
    1997, Educational video game for juvenile diabetes: results of a controlled trial. Medical Informatics,
    22, 77 ­ 89.
12. LOBENE, R.R., WEATHERFORD, T., ROSS, N.M., LAMM, R.A. and MENAKER, L., 1986, A modified
    gingival index for use in clinical trials. Clinical Preventive Dentistry, 8, 3 ­ 6.
13. SILNESS, J. and LOE, H., 1964, Periodontal disease in pregnancy. II Correlation between oral
                        ¨

    hygiene and periodontal condition. Acta Odontologica Scandinavica, 22, 121 ­ 135.
14. O'LEARY, T.J., DRAKE, R.B. and NAYLOR, J.E., 1972, The plaque control record. Journal of Perio-
    dontology, 43, 38.
15. AXELSSON, P. and LINDHE, J., 1981, Effect of controlled oral hygiene procedures on caries and
    periodontal disease in adults. Results after 6 years. Journal of Clinical Periodontology, 8, 239 ­ 248.
16. ADDY, M., RENTON-HARPER, P., WARREN, P. and NEWCOMBE, R.G., 1999, An evaluation of video
    instruction for an electric toothbrush. Comparative single-brushing cross-over study. Journal of
    Clinical Periodontology, 26, 289 ­ 293.
17. ABRAMS, D.B., ORLEANS, C.T., NIAURA, R.S., GOLODSTEIN, M.G., PROCHASKA, J.O. and VELI-
    CER, W., 1996, Integrating individual and public health perspectives for treatment of tobacco
    dependence under managed health care: a combined stepped-care and matching model. Annals of
    Behavioral Medicine, 18, 290 ­ 304.
18. GOLDER, D.T. and BRENNAN, K.A., 2000, Practicing dentistry in the age of telemedicine. Journal of
    American Dental Association, 131, 734 ­ 744.


