European Archives of Paediatric Dentistry

https://doi.org/10.1007/s40368-019-00457-1

ORIGINAL SCIENTIFIC ARTICLE

Smartphones and tooth brushing: content analysis of the current

available mobile health apps for motivation and training
K. Hotwani1 · K. Sharma2 · D. Nagpal1 · G. Lamba1 · P. Chaudhari1

Received: 20 April 2018 / Accepted: 27 May 2019

© European Academy of Paediatric Dentistry 2019

Abstract
Introduction  Smartphone mobile app is an innovative concept for health behaviour‐based interventions.
Aim  The present study aimed to analyse apps developed for smartphones that promote tooth brushing amongst children
using the Coventry, Aberdeen, and London-Refined (CALO-RE) taxonomy for behaviour change.
Materials and methods  Tooth brushing apps available in English and free to download that purported to assist with brush-
ing were searched on the Apple app store using search terms based on Boolean logic and included AND combinations for
keywords tooth brushing, children, toothbrush and motivation in the health and fitness category; six apps met the inclusion
criteria and were downloaded. The behaviour change taxonomies were assessed individually for each app and scored as per
coding and analysed for presence or absence.
Results  Only three of the behaviour change taxonomies were present in all apps, i.e. information provision (general), goal
setting (behaviour) and prompt practice. Setting graded tasks, self-monitoring of behavioural outcome, demonstration of
behaviour, prompt use of imagery and time management were included in four out of six apps.
Conclusion  The present study explores a new arena for oral healthcare motivation and prevention in children through the
use of mobile phone apps.

Keywords  Smartphones · Toothbrushing · App

Introduction without great changes. Still, it is commonly recognised that

Oral health is an indispensable part of general well‐being.
Dental caries is a major oral health problem in developing
countries, affecting 60–90% of the school children (Petersen
2003; Petersen et al. 2005). Proper maintenance of oral
hygiene through tooth brushing is the most widely used
method to avert dental caries (Jepsen et al. 2017).
Tooth brushing is acquired during the socialisation pro-
cess of the child (Leal et al. 2002). When this habit is taught
in early childhood, it is naturally embedded in the day-to-
day routine of the child, following affirmative reinforcement
(Pareek et al. 2015). Tooth brushing can be compared with
other health-related habits that will persist throughout life
* K. Hotwani
hotwani.kavita@gmail.com
1
Department of Pediatric and Preventive Dentistry, VSPM’s
Dental College and Research Center, Nagpur, Maharashtra,
India
2 cator of potential effectiveness of an app.
Toothart Comprehensive Dental Care, Nagpur, India
tooth brushing by children under 10 years of age is inept.
Nevertheless, the optimal and psychological approaches
for encouraging proper tooth brushing in children are still
contentious; innovative concepts for health behaviour‐based
interventions have begun to emerge. One such tool for
patient education/communication and healthcare provider
is smartphone mobile app. Mobile apps are software pro-
grammes that run on smartphones and other mobile devices.
Over 75 billion apps have been downloaded from the Apple
app store since its launch in 2008, with over 50 billion apps
downloaded from Google Play (Underwood et al. 2015).
Despite the fact that many children and adults do not comply
with tooth brushing recommendations, smartphone applica-
tions (apps) that promote oral hygiene are popular. Apps
are fairly innovative tools for tooth brushing motivation and
very little research has been published on the content and
the effectiveness of these apps in terms of behaviour change
(Underwood et al. 2015). It can be proposed that the pres-
ence of behaviour change techniques/taxonomies is an indi-

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A number of taxonomies of behaviour change, including
generic taxonomies and those relating to specific behaviours
such as alcohol reduction, promoting physical activity and
healthy eating and smoking cessation have been developed
(Klasnja and Pratt 2012; Middelweerd et al. 2014; Ubhi et al.
2016).
Recent studies have concluded that health promoting apps
lack the use of behaviour change taxonomies in promoting
behaviour changes such as smoking cessation, weight loss,
and increased physical activity (Middelweerd et al. 2014).
Therefore, the present study aims to analyse apps developed
for smartphones that promote tooth brushing amongst chil-
dren using the Coventry, Aberdeen, and London-Refined
(CALO-RE) taxonomy for behaviour change (Michie et al.
2011).
Study design
Tooth brushing apps available in English and free to down-
load that purported to assist with brushing were searched on
the Apple app store (www.apple​.com/itune​s) using search
terms based on Boolean logic and included AND combi-
nations for keywords tooth brushing, children, toothbrush
and motivation in the health and fitness category; six apps
met the inclusion criteria and were downloaded (Fig. 1).
Descriptions of each app were located online, reviewed
and coded independently by principal investigator using the
adapted Coventry, Aberdeen, and London-Refined (CALO-
RE) taxonomy for behaviour change.
Coding and rating of app
The apps were coded on a quantitative scale on each item
of the CALO-RE taxonomy adapted and modified for tooth
brushing behaviour change (Table 1). Each item was coded
as 0 indicating “not present at all” and 1 indicating “pre-
sent”. The behaviour change taxonomies were assessed
individually for each app and scored as per coding and ana-
lysed for presence or absence. App rating was recorded as
percentage of features that was present in the app related to
behaviour change.
Results
The behaviour change taxonomy included in all apps
(100%) was information provision (general), goal setting
(behaviour) and prompt practice. Goal setting (outcome),
action planning, informing when and where to perform the
behaviour and instruction on how to perform the behaviour
were included in five out of the six apps (83%). Setting
graded tasks, self-monitoring of behavioural outcome, dem-
onstration of behaviour, prompt use of imagery and time
management were included in four out of six apps (66%).
Few of the apps included training to use prompts, use of
follow up prompts, to facilitate social comparison and self-
monitoring of behaviour change taxonomy. The taxonomies
which were not found in any of the tooth brushing apps
are depicted in Table 2. Figure 2 depicts the app rating as
recorded in percentage by features that were present in the
app related to behaviour change.
Discussion
As paediatric oral healthcare takes the high-tech stride, it is
important to establish and maintain effective tooth brushing
habits in children. Oral hygiene maintenance has undergone
recent developments that have changed a monotonous mat-
ter to extraordinary progress and research. In addition, the
public’s consciousness regarding home oral hygiene also has
been raised to new levels by the advertising of home health-
care products. Health and cosmetic awareness by patients
are possibly at an all-time high; they are willing to pay for
the best in health products.

Fig. 1  Tooth brushing apps

coded

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European Archives of Paediatric Dentistry
Table 1  CALO-RE taxonomy adapted for tooth brushing behaviour
Information provision (general)
Information provision (to the individual)
Information provision (others’ approval)
Information provision (others’ behaviour)
Goal setting (behaviour)
Goal setting (outcome)
Action planning
Identifying barriers/problem resolution
Setting graded tasks
Review of behavioural goals
Review of outcome goals
Effort or progress contingent rewards
Successful behaviour contingent rewards
Shaping
Generalisation of target behaviour
Self-monitoring of behaviour
Self-monitoring of behavioural outcome
Focus on past success
Provide feedback on performance
Informing when and where to perform the behaviour Offering advice and ideas on when and where a physical activity could be performed
Instruction on how to perform the behaviour
Demonstration of behaviour
Training to use prompts
Environmental restructuring
Agreement of behavioural contract
Prompt practice
Provision of general information about tooth brushing and its possible outcomes
Provision of specific information relevant to the individual about tooth brushing for his
age, oral health status, its possible outcomes, consequences and benefits
Provision of information about what others might think of their tooth brushing habits
Provision of information concerning what others typically do with respect to tooth brush-
ing
Encouragement to begin or maintain behaviour change. It does not involve precise plan-
ning for the behaviour sequence or performance. A goal may be to “brush twice daily
from next week”
The individual is encouraged to set general goals achievable through performance of the
behaviour, but distinct from the behaviour itself. A consultant might highlight good
periodontal health or decrease in halitosis as achievable goals derived from regular tooth
brushing
Detailed plans are made including when (e.g. frequency) and where (e.g. in what situa-
tion) to act. Such plans are often expressed in “if–then” formats. For example, a child
might plan this “if I win this game, then I will brush twice a day”
After formation of a clear plan, individuals are tasked with identifying possible barriers
to performance and solutions to the possible problems. Barriers may be cognitive, emo-
tional, social and/or physical. For instance, “I don’t get time to brush properly because of
school rush,—therefore, I will go to sleep earlier every day”
The target behaviour is broken into smaller, more manageable tasks, allowing successful
progression in small increments
For instance, writing down a sequence of small steps to accomplish the overall behaviour
over time
An opportunity for the individual to review the successful accomplishment of previously
set goals
A review or analysis of the attainment of previously set outcome goals, and an opportunity
to revise plans to attain them
The person uses rewards or praise for attempts at achieving the goal
Providing rewards for successful performance of the target behaviour
Graded contingent rewards for movements towards completion of the target behaviour
After successful performance of a behaviour in one situation, the person is encouraged to
find opportunities to try it in other situations, ensuring the behaviour does not become
situation specific
The person is asked to keep a detailed record of their activity and use as a means to
change or modify behaviour
As point 16, but focusing on measurable outcomes of the behaviour (e.g. plaque reduc-
tion)
Using reflections on successful past experience with physical activity as a means to
increase motivation to be active in future
Provision of feedback to an individual regarding a recent physical activity success with the
aim of increasing motivation to be more active in future
Instructing a person exactly how to effectively perform a behaviour
Showing the person how to perform an activity, through physical or visual means
Instruction on use of cues to help remind people to perform a behaviour. For instance,
encouraging tooth brushing use and increasing frequency of brushing or mobile phone
alerts to remind them
The person is prompted to make changes to their environment to facilitate changes in
behaviour
A written agreement between the individual and the practitioner with respect to behaviour
change
Reminding the person to rehearse and repeat the behaviour or situations that lead to the
behaviour. This helps reinforce the activity and make it more automated or habitual so
that it becomes part of a person’s daily routine
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Table 1  (continued)

Use of follow up prompts Use of reminders delivered after a person has started a behaviour change routine to help
remind them to continue
Facilitate social comparison Individuals are encouraged to draw comparisons with others behaviour to increase motiva-
tion through modelling
Plan social support Prompt the person to elicit social support from other people and close relations to facili-
tate person’s successful completion of the behaviour
Prompt identification as role model The person views themselves as an example or role model to others for the behaviour
Prompt anticipated regret Induce expectations of shame, regret or guilt for failure to accomplish the goal
Fear arousal The presentation of fear-inducing information aimed at motivating change
Prompt self-talk The person is encouraged to talk to themselves before and during their activity to provide
verbal encouragement and support
Prompt use of imagery The person is provided with instruction on how to use visualisation techniques and
imagery to facilitate successful completion of the behaviour
Relapse prevention The person is encouraged to make plans to maintain behaviour that has been changed
Stress management The person is encouraged to focus on reducing related stress and improving emotional
control to reduce this as a barrier and promote health
Motivational interviewing A clinical method including specific techniques to prompt changes by minimising resist-
ance and resolving ambivalence to change
Time management Any technique that assists the person in managing their time efficiently, so as to be able to
engage in the desired activity. For instance, effectively using a diary or organiser to plan
time
Communication skills training Techniques directed at improving communication skills to improve interactions with oth-
ers about the behaviour
Stimulate anticipation of future rewards Individuals are encouraged to consider future rewards associated with the outcome(s),
without necessarily reinforcing behaviour change

Table 2  Taxonomies which were not found in any of the tooth brush-
ing apps
Review of behavioural goals
Review of outcome goals
Agreement of behavioural contract
Prompt identification as role model
Prompt anticipated regret
Fear arousal
Prompt self-talk
Relapse prevention
Stress management
Motivational interviewing
Tooth brushing is the main oral hygiene behaviour, and
even though it is widely associated to good oral health,
most people do not perform it thoroughly enough to pre-
vent accumulation of dental plaque. Most oral hygiene
interventions are based on motivation and development of
aptitude. Wendt et al., observed that if the habit of daily
tooth brushing is adopted at as early as 1-year-old, it is
more likely that children will be caries free by the age of 3
(Wendt et al. 1994). Consequently, for an optimal primary
prevention, children should be instructed on how to remove
dental plaque. Moreover, to assess the learning process in
performing tooth brushing, it is necessary not only to estab-
lish a dental health education programme, but also to use a
motivational reinforcement. It is not just adults who own a
device capable of running mobile apps as reports suggest
that 6-year-olds understand digital technology better than
adults (Underwood et al. 2015). Successful oral hygiene
behaviours are those that are performed in a timely manner
and with good technique.
It is suggested that the most common facilitators for tooth
brushing are positive oral health beliefs such as effective-
ness of oral hygiene, social norms, emotional reactions to
the consequences of not brushing teeth, high self-standards,
make it part of a routine, and find ways to make it easier
(Huebner and Riedy 2010). Teaching tooth brushing and
turning it into a habit require that parents create a routine
that includes helping their children develop the necessary
skills and talk to their children to help them understand the
importance of this process.
The advent of smartphone apps for tooth brushing has
added a new arena to oral hygiene awareness in terms of
motivation, training and gamification for children. Certain
behaviours need special skills for them to be performed.
Tooth brushing has been defined as a complex skill (Milten-
berger 2007). It involves a motor component (toothbrush
grip and dexterity) and a cognitive component (understand-
ing of the process and its goal). People at different ages have
different skills. During the first years of life, the human body
and mind changes at exponential rates. Developmental skills
such as the ability to process new knowledge, appreciate

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European Archives of Paediatric Dentistry

Fig. 2  Individual rating of apps App rang (Percentage %)

as per taxonomy scores

Brush DJ 25

Toothsavers Brushing Game 75

Brush Up: The Toothbrush Training Game 35

Brush Teeth - Toothbrush Timer & Dental
30
Brushing!
Brusheez - The Lile Monsters Toothbrush
30
Timer
Toothbrush Time with Icky 27.5

their environment and control motor skills change during
childhood and this should be considered when designing
an intervention (Miltenberger 2007; Saklofske et al. 2013).
Patient compliance with a smartphone app is thought
to be more convenient due to the fact that the individual
is able to utilise the app directly from their smartphone,
therefore eliminating the need for separate device or sys-
tem. Reminders and prompts for new behaviours or habits
can be customised for the individual. Many advantages of
using the Internet as a delivery mode apply to smartphone
apps too: constantly accessible, adjustable to the needs of
the user, able to provide tailored feedback, large reach and
interactive features. Therefore, apps offer new opportuni-
ties to deliver individually tailored interventions including
real-time assessment and feedback that are more likely to be
effective (Middelweerd et al. 2014; Wang 2015).
In the present study, the apps were rated based on the
CALO-RE taxonomy of behaviour change. The CALO-
RE taxonomy formulates a comprehensive and standard-
ised protocol for the identification, reporting and appraisal
of behaviour change interventions for health behaviours.
Behaviour change approaches to implementation science
provide an opportunity to draw upon decades of applied
research in behavioural medicine and social and health psy-
chology regarding the techniques that can be used to change
behaviour. A behaviour change technique (BCT) is defined
as “an observable, replicable, and irreducible component
of an intervention designed to alter or redirect causal pro-
cesses that regulate behaviour”. First published in 2011, the
CALO-RE taxonomy contains 40 techniques derived from
behaviour change theories. It was designed to help develop-
ers of new interventions identify and apply evidence-based
techniques. The CALO-RE taxonomy has been widely used
to characterise physical activity interventions such as smart-
phone apps, health coaching and interventions for preventing
and managing obesity in children (Michie et al. 2011; Mid-
delweerd et al. 2014; Mercer et al. 2016). The assessment
for the likely effectiveness of apps in terms of use of specific
‘behaviour change techniques’ is associated with higher suc-
cess rates. This method provides a way of characterising the
content of behaviour change interventions using a language
that is consistent across interventions and behaviours (Ubhi
et al. 2016). Much research suggests that health interven-
tions designed around health behaviour theory are more
effective in changing behaviour than those which are not.
Many content analyses of health apps indicate that such apps
generally contain low levels of HBT or are not adequately
designed for long-term behaviour change (Payne et al. 2015).
The results of the present investigation are in accord-
ance with Breton et al., who noted in a content analysis of
weight loss apps that most contained few evidence-based
practices, and Cowan et al., reported in a content analysis of
physical activity apps that the sample contained low levels
of HBT, suggesting that the lack of behavioural components
may have been due to the widely varying professional back-
grounds of app developers (Breton et al. 2011; Cowan et al.
2013).
At least two behaviour change techniques were identified
in each of the apps included in the study, which suggests
that app developers attempt to use behaviour change theory
to some extent. However, the results also indicate that the
inclusion of established behaviour change techniques is far
from optimal in most apps. The current review provides
information about the content of apps, but future research
should study how behaviour change techniques can be trans-
lated into apps. Additionally, future research should exam-
ine the effectiveness of apps and which behaviour change
techniques or combinations of techniques are more effec-
tive. This review indicates that apps have the potential to
provide tailored feedback and to integrate behaviour change

13

techniques. A collaboration between app developers, health
professionals and behaviour change experts could increase
the use of behaviour change techniques in apps and may
open a new scale of possibilities in health promotion.
Conclusion
The present study explores a new arena for oral healthcare
motivation and prevention in children through the use of
mobile phone apps. However, the results indicate that very
few apps have included the behaviour change taxonomies in
their features. Also, the inclusion of a gaming environment
with better focus on individual training based on national
guidelines would be desirable for any app on tooth brushing.
These apps would be an emerging option for oral hygiene
behavioural change, as it would address innate psychologi-
cal needs whilst offering intrinsic motivation in the form of
fun for the child.
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