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. 2022 May 19;17(5):e0263638. doi: 10.1371/journal.pone.0263638

A naturalistic study of brushing patterns using powered toothbrushes

Mahmoud Essalat 1,*, Douglas Morrison 2, Sumukh Kak 3, E Jun Chang 4, Isabel Roig Penso 3, Rachel J Kulchar 5, Oscar Hernan Madrid Padilla 6, Vivek Shetty 7
Editor: Tanay Chaubal8
PMCID: PMC9119504  PMID: 35587489

Abstract

Dental caries and periodontal disease are very common chronic diseases closely linked to inadequate removal of dental plaque. Powered toothbrushes are viewed as more effective at removing plaque; however, the conflicting evidence and considerable unexplained heterogeneity in their clinical outcomes does not corroborate the relative merits of powered tooth brushing. To explain the heterogeneity of brushing patterns with powered toothbrushes, we conducted a observational study of tooth brushing practices of 12 participants in their naturalistic setting. Integrated brush sensors and a digital data collection platform allowed unobtrusive and accurate capture of habitual brushing patterns. Annotated brushing data from 10 sessions per participant was chosen for scrutiny of brushing patterns. Analysis of brushing patterns from the total 120 sessions revealed substantial between- and within-participant variability in brushing patterns and efficiency. Most participants (91.67%) brushed for less than the generally prescribed two minutes; individual participants were also inconsistent in brushing duration across sessions. The time devoted to brushing different dental regions was also quite unequal. Participants generally brushed their buccal tooth surfaces more than twice as long as the occlusal (2.18 times longer (95% CI 1.42, 3.35; p < 0.001)) and lingual surfaces (2.22 times longer (95% CI 1.62, 3.10; p < 0.001); the lingual surfaces of the maxillary molars were often neglected (p < 0.001). Participants also varied in the epochs of excessive brushing pressure and the regions to which they were applied. In general, the occlusal surfaces were more likely to be brushed with excessive pressure (95% CI 0.10, 0.98; p = 0.015). Our study reveals that users of powered toothbrushes vary substantially in their use of the toothbrushes and diverge from recommended brushing practices. The inconsistent brushing patterns, between and within individuals, can affect effective plaque removal. Our findings underscore the limited uptake of generic oral self-care recommendations and emphasize the need for personalized brushing recommendations that derive from the objective sensor data provided by powered toothbrushes.

Introduction

Dental caries and periodontal disease are very common chronic diseases closely linked to inadequate oral self-care [1,2]. Scientific evidence indicates that regular and systematic toothbrushing prevents the accumulation of dental plaque that leads to gum disease, tooth decay, and eventually, tooth loss [3,4]. Thus, most efforts to reduce the incidence and impact of dental disease focus on toothbrushing techniques and strategies that reduce the accumulation of plaque. Although manual toothbrushes are the most commonly used tools for plaque control, powered toothbrushes are gaining increasing acceptance as alternatives, especially for children, people with disabilities or limited mobility, and older adults. Automated powered toothbrushes minimize the manual efforts of brushing and incorporate timers to reinforce brushing duration; thus, they are viewed as more effective at removing plaque than manual brushes [5]. Despite a substantial heterogeneity (I(2) > 80%) in plaque removal, the Cochrane meta-analyses found that powered toothbrushes produced an 11% reduction in plaque at one to three months of use and a 21% reduction in plaque after three months of use [5].

The considerable heterogeneity in plaque removal with powered toothbrushes (I(2) > 80%) observed in the Cochrane study [5], could not be explained by the difference in types of powered toothbrushes and more likely derives from by varying brushing patterns. For toothbrushing to be effective, all dental surfaces need to be cleaned frequently and adequately; otherwise, the practical value of toothbrushing is low. Brushing frequency, duration, and technique are key determinants of adequate plaque reduction and optimal oral self-care.

Brushing techniques commonly recommended by dental professionals [6] are based on manual toothbrushes [6,7]. They do not readily translate to brushing with powered toothbrushes where the user guides but does not animate the brush head. Studies that have attempted to clarify brushing patterns with powered toothbrushes have largely focused on between-individual variations determined through video recordings obtained in controlled clinical settings [8]. Such snapshot observations ignore within-participant variations in brushing behaviors and patterns across multiple sessions. Moreover, the external validity of the assessments in simulated environments suffers because brushing behavior patterns recorded in research settings may not reflect naturalistic, real-world practices.

To explain the heterogeneity of brushing patterns with rotation-oscillation powered toothbrushes, we conducted an observational study of individuals in their home settings. Sensors embedded within the powered toothbrush and concurrent video recordings of brushing sessions ensured data fidelity and ecological validity across multiple days. Our objective was to gather accurate data on habitual brushing patterns using powered toothbrushes, with a focus on the duration of each session, tooth surfaces covered, and episodes of excessive brushing pressure per session. By examining habitual brushing patterns at the individual and session-level, we sought to clarify between-person and session-to-session variability in brushing patterns and efficiency using powered toothbrushes.

Materials and methods

This study comprised part of a larger study involving machine learning approaches to characterize toothbrushing behaviors and develop a brushing efficiency score. As part of the parent study, 12 healthy college students with no evident dental disease, provided their brushing data in the home setting over three weeks (50 sessions each). Basic instruction on the use of the brush and setting up the data collection system was given and the participants were instructed to freely brush their teeth in a manner most natural to them. All participants provided written informed consent and the study protocol was reviewed and approved by the Institutional Review Board of the University of California, Los Angeles (IRB#18–000874).

Data collection infrastructure

To allow objective, individual-level, and ecologically-valid data on oral hygiene behaviors, we deployed the Remote Oral Behaviors Assessment System (ROBAS) described previously [9]. Briefly, ROBAS builds on a broadly available consumer-grade powered toothbrush (Oral-B Genius X; Procter & Gamble) as the data source for brushing behaviors (timing, duration, pressure applied). The Oral-B brush employs a rotational-oscillation mode of action and brushing movements are captured by an accelerometer, gyroscope, and pressure sensor contained within the powered brush. Captured data is transmitted over BLE (Bluetooth Low Energy) to a paired smartphone running the companion data collection app. Collected data is then uploaded to a secure cloud server for remote monitoring of data yields and analytics. Visualization of time-series data streams of brushing episodes and remote monitoring of sensor function and participant compliance is accomplished through an adaptation of the open platform Grafana™ dashboard [10].

Data collection

Upon enrollment, each participant was provided an Oral-B powered toothbrush, a suction-cup phone mount, charger, and quick-start instructions. Participants downloaded the study-specific app onto their own smartphone and paired it to the powered brush. Participants were instructed on the operation of the powered brush and on how to mount the smartphone to their bathroom mirror during a brushing session for the duration of the study (3 weeks). Participants were instructed to brush twice daily for two minutes each time. At the start of each brushing session, participants launched the study app and activated the smartphone camera. Data from the embedded sensors was buffered by the brush and transmitted to the study phone via Bluetooth. Turning off the toothbrush ended data collection and triggered the app to save the timestamped brushing data. The brushing session data and the corresponding videoclip were then uploaded via the ROBAS platform to a secure cloud server for subsequent analysis. The ROBAS platform with integrated Grafana™ dashboard allowed research staff to remotely monitor data feeds and conduct quality checks.

Data processing and annotation

We selected 10 sessions (out of the 50 recorded sessions per participant) at random for a total of 120 brushing sessions across the 12 participants. To establish ground truth information, trained and calibrated researchers reviewed and annotated the individual video recordings, focusing on tooth surface coverage as well as brushing duration of each surface. Every epoch of brushing a dental region that lasted more than 0.5 second was labeled by marking the beginning and end timestamp of that brushing epoch. Because the study phone camera recorded at 1080 p at 30 fps (frames-per-second), we were able to get a 33 ms time resolution for the ground truth data. The annotated video timestamps were then aligned with the sensor signal time stamps. An experienced examiner conducted random audits of labeled data and provided corrections on annotation errors.

Dental regions (Fig 1) were characterized using the convention proposed by Lee et al. [11]. Briefly, dental regions are labeled by jaw (maxilla or mandible), side (right, anterior or left), and tooth surface (buccal, lingual, or occlusal).

Fig 1. 16 dental surfaces considered in this study (image retrieved from [11]).

Fig 1

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Analyses

All statistical analysis was performed in R version 4.1.1 [12], using the regression modeling package “glmmTMB” [13]. The boxplots are generated using Matlab R2021a [14]. The dataset used as well as the code to generate the results are publicly available publicly at a GitHub repository [15].

Several participants skipped some regions altogether in some or all brushing sessions, and most participants avoided using excessive pressure most of the time. Therefore, the durations of region-specific brushing and region-specific brushing with excessive pressure were often equal to zero, a statistical phenomenon referred to as zero-inflation [13]. Accordingly, we analyzed these outcomes using statistical models that account for zero-inflation. Specifically, we modeled these outcomes (each measured in counts of 25Hz samples) using zero-inflated generalized linear mixed-effects regression models, with a log-link and a negative binomial outcome distribution for the count submodels and a logistic link and a Bernoulli outcome distribution for the zero-inflation submodels. Both submodels had fixed effects for tooth surface, mouth side, and jaw, and to capture between- and within-participant variabilities, had random effects on the intercept by session nested in participant, to account for person-to-person and session-to-session differences in overall brushing duration, and person-specific overdispersion parameters to account for person-to-person differences in residual variance. The count submodel for region-specific brushing duration also included participant-specific random effects for tooth surface, mouth side, and jaw (see S1 Appendix A1 for details); the count submodel for region-specific excessive pressure duration failed to converge when random effects were added for these covariates, since many participants never brushed with excessive pressure in some or all regions.

We calculated the total active brushing duration per-session by excluding pauses in brushing and the epochs of transitioning the brush head to different dental surfaces. We modeled this outcome using a negative binomial generalized linear mixed-effects regression model (not zero-inflated, since all brushing sessions had duration greater than zero) with random intercepts by participant and fixed effects for participant-specific dispersion (see S1 Appendix A3 for details).

To examine the data on different levels, we used boxplots. Data points were labeled as outliers if they were not in the range of [q1—w * (q3-q1), q3 + w * (q3-q1)]; in which w is the Whisker value and q1 and q3 are the 25th and 75th percentiles of the sample data, respectively. We used a whisker value of ±2.7σ (σ is the standard deviation of the sample data) that corresponds to the coverage of 99.3% of the data, if the data is normally distributed. The significance-level (ɑ) was set at 5%.

Results

The 12 participants comprised of eight females and four males with ages ranging from 18 to 23 years (20.77 ± 1.59).

Total active brushing duration in each session

We calculated the active brushing duration by excluding pauses in brushing and the times transitioning the brush head to different regions. Fig 2 summarizes the active brushing duration for all participants. Most of the participants (91.67%) brushed less than the prescribed two minutes in all sessions. The mean brushing duration for a participant was 89.22 seconds.

Fig 2. Brushing durations for the 12 participants.

Fig 2

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Active brushing duration is calculated by excluding pauses in brushing and the times transitioning the brush head to different regions.

There was substantial between- and within- individual variability in brushing duration. Observed between-participant variability was 16.69 seconds (see Table A3.2.5 in S1 Appendix; coefficient of variation = 0.19 > 0.05) and observed within-participant variability was 14.50 seconds (see Table A3.2.5 in S1 Appendix; coefficient of variation = 0.17 > 0.05). Some participants (e.g. # 1 and 2) brushed for almost two minutes in most sessions, whereas others (e.g. participant 5) brushed for less than a minute. Some participants (e.g., 2, 4, and 7) brushed consistently for nearly the same duration each time; others (e.g., # 5, 9, and 12) varied greatly (> 70 seconds) in their brushing duration.

Brushing duration for each dental surface

Fig 3 summarizes the brushing duration of each region for all participants. MaxAB, MaxLB, and MaxRB were the areas brushed the longest with a median of 10.68, 8.78, and 8.22 seconds respectively. In contrast, MaxLL and MaxLO were frequently skipped during brushing.

Fig 3. Group-level brushing time of all dental surfaces.

Fig 3

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MaxAB, MaxLB, and MaxRB were the areas brushed the longest and in contrast, MaxLL and MaxLO were frequently skipped during brushing.

Brushing time categorized by different regions is shown in Fig 4. Participants did not vary significantly in the brushing times spent on the maxillary and mandibular regions or different sides (right, anterior, and left). However, participants differed in the times spent brushing various teeth surfaces with buccal surfaces brushed significantly more than the lingual and occlusal surfaces. On average, buccal surfaces were brushed 2.18 times longer than the lingual surfaces (see Table A1.2.1 in S1 Appendix; 95% CI 1.42, 3.35; p < 0.001) and 2.22 times longer than the occlusal surfaces (see Table A1.2.1 in S1 Appendix; 95% CI 1.62, 3.10; p < 0.001).

Fig 4. Group-level brushing times of different dental regions.

Fig 4

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Categorized by (A) jaw, (B) side, and (C) surface. Buccal surfaces were brushed twice more than the lingual and occlusal surfaces.

Between-individual variability in brushing duration

There was considerable between-individual variability in terms of brushing time devoted to different regions (Fig 5). Coefficient of variation for all the regions brushed during a session was greater than 20%. (see S1 Appendix A2). Some (e.g. participant 7) brushed their maxillary teeth much more than their mandibular teeth (see Table A1.2.6 in S1 Appendix; p < 0.001). Others (e.g. participant 11), paid less attention to their lingual surfaces and focused primarily on the buccal surfaces (see Table A1.2.6 in S1 Appendix; p = 0.001).

Fig 5. Between-individual variability in brushing duration by region.

Fig 5

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(A) by jaw and (B) by tooth surface.

Within-individual variability in brushing duration

Participants varied greatly in their brushing of different regions across their brushing sessions. As exemplified by the brushing patterns of participant 2, the brushing duration for the lingual surfaces across sessions varied from none to 60 seconds (Fig 6).

Fig 6. Within-individual variability in brushing duration for dental surfaces.

Fig 6

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Participant 2’s brushing duration for the lingual surfaces varied greatly across sessions.

Episodes of excessive brushing pressure

Fig 7 summarizes the episodes of excess brushing pressure by region. About 16.7% of the participants exerted excessive brushing pressure of more than one second duration during each brushing session. Also, the occlusal surfaces were most frequently brushed with excessive pressure (see Table A2.2.1 in S1 Appendix; estimated log relative duration = 0.54; 95% CI 0.10, 0.98; p = 0.015).

Fig 7. Episodes of excessive brushing pressure by region.

Fig 7

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Occlusal surfaces were most frequently brushed with excessive pressure.

Discussion

Our study revealed that brushing patterns with powered toothbrushes in the home setting varied greatly between individuals as well as within individuals. Although the electronic brushes incorporated timers and study participants were aware that their sessions were being monitored, most participants brushed their teeth for less than the prescribed two minutes. Even individual participants were inconsistent in the total duration of time they spent brushing over different days. The times devoted to brushing different dental regions are quite unequal at the individual level with certain regions receiving more attention than the others. Participants generally brushed the buccal tooth surfaces twice as long as the occlusal and lingual surfaces; the lingual surfaces of the maxillary molars were often neglected.

The varying brushing patterns and unequal coverage of dental surfaces has implications for systematic and thorough brushing behavior. There are manifest discrepancies between professional recommendations on brushing techniques and what is actually practiced in the home setting. Our study participants were aware that their brushing behaviors were being monitored remotely; yet, they rarely brushed for the entire 120 seconds recommended by dentists. Most spent less than 85 seconds per brushing session, a finding consistent with other studies that indicate that patients often fail to adhere to the recommended brushing time of two minutes [16]. Increased brushing time is linked to better plaque removal and Gallagher et al [17] showed that brushing with manual brushes for 120 seconds removed 26% more plaque than brushing for 45 seconds. Despite the putative advantage, integrated timers alone may not facilitate adherence to recommended brushing times and need to be reinforced by other ways of engaging individuals.

Beyond the differences in total brushing times with the powered toothbrushes, the variability in the time devoted to brushing each region suggested inefficient brushing practices. Irrespective of the mode of action of the powered brush (i.e., rotating-oscillating or reciprocating), if a dental region is neglected, the plaque removal will be incomplete. The variability in brushing times and dental region coverage may explain some of the considerable heterogeneity in plaque removal reported by the 2014 Cochrane meta-analyses of powered toothbrushes [5].

Our observation that participants tended to brush tooth surfaces unequally substantiates other studies [16,18–20]. Whereas some studies found that lingual surfaces are brushed significantly less than both occlusal and buccal surfaces [16,19], we did not find any statistically significant difference between the times spent brushing the occlusal and lingual surfaces. Also, participants varied in the epochs of excessive brushing pressure and the regions to which they were applied. In general, the occlusal surfaces were more likely to be brushed with excessive pressure. Only a subset (16.7%) of our participants exerted excessive brushing pressures and these were mostly transient (~1 second). This finding contrasts Janusz et al. [21] who reported that 46.3% of their participants exerted excess brushing pressures for more than four seconds within a two-minute brushing session.

Our technology-facilitated study has several strengths. Unlike previous observational studies with limited external validity, our naturalistic study is more representative of real-world brushing behaviors and patterns. We have previously shown that our data collection infrastructure (ROBAS) has a high accuracy for measuring oral health behaviors and can passively and reliably capture brushing behaviors in the home setting for extended periods [9]. The unobtrusive data collection helps distinguish between person-to-person variability and within-person session-to-session variability via a repeated measurement study design. Anchored by corresponding video recordings of brushing sessions, the data from the brush sensors can be used to accurately reconstruct brushing motions and infer coverage of a dental region. Furthermore, it allows us to ignore pauses and transitions of the brush head and focus on actual brushing times when the brush was in contact with tooth surface. The ecologically-valid measurement of brushing efficiency and the finding of inconsistent brushing patterns set the stage for personalized feedback on brushing patterns. Thus, an individual neglecting to brush a dental quadrant for at least 30 seconds or ignoring certain dental regions could be provided individually tailored feedback and behavioral nudges to improve brushing efficiency. Study limitations include the fact that the study participants were recruited as a convenience sample and involved a young well-educated and dentally-aware group of college students. This may limit the generalizability of our findings to an older and more socioeconomically diverse population.

In summary, our study reveals that users of powered toothbrushes vary substantially in their application of powered toothbrushes and diverge from recommended brushing practices. The inconsistent brushing patterns, between and within individuals, may result in inefficient brushing behaviors.

Our findings underscore the limited uptake of generic oral self-care recommendations and emphasize the need for personalized brushing recommendations that derive from the objective sensor data provided by powered toothbrushes. Simply asking individuals to brush longer or more frequently may not result in a more thorough brushing behaviors.

Supporting information

S1 Appendix. Statistical analysis.

(DOCX)

Click here for additional data file. (212.5KB, docx)

Acknowledgments

The authors wish to acknowledge the material support provided Oral-B/Procter & Gamble. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Procter & Gamble.

Data Availability

The dataset used as well as the code to generate the results are publicly available publicly at a GitHub repository. Essalat, M., & Morrison, D. (2022). Brushing-Behavior (Version 1.0.0) [Computer software]. https://doi.org/10.5281/zenodo.1234.

Funding Statement

Research reported in this publication was supported by the National Institute of Dental and Craniofacial Research under award number R01DE025244 and 1UG3DE028723-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Decision Letter 0

Tanay Chaubal

7 Mar 2022

PONE-D-22-02067A naturalistic study of brushing patterns using electric toothbrushesPLOS ONE

Dear Dr. Mahmoud Essalat,

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Additional Editor Comments:

Dear Dr Mahmoud Essalat,

I congratulate you on writing a manuscript on a novel concept.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: The authors have conducted a study on 12 participants to study their natural brushing habits using a rotation oscillation toothbrush. This study attempts to aggregate the data that is available when participants use these brushes at home rather than a professional setting. Although this is a strength of this study, the study does not appear to provide sufficient aggregated statistical data (although it appears that it was done) to substantiate the results and conclusions from the study. The study also might be under powered with only 12 participants (the authors have not provided how the sample size was arrived at).

GENERAL COMMENTS:

The authors use the word electric toothbrushes throughout the study (and title). Since the type of toothbrush studied here was only of the rotation oscillation type, it cannot be generalized to all types of electric toothbrushes. The authors need to use more specific language across the full text and title to correctly represent what is being studied.

In addition, it appears that the participants were video recorded during all sessions of tooth brushing (needs clarification from authors). Although it might be closer to their natural home practices than studying it in a professional setting, it still does not fully resemble a naturalistic brushing patters. Consider rewording the title and abstract/full text information to “at home” rather than naturalistic.

ABSTRACT:

1. Abstract states “analysis of brushing patterns from 120 sessions” – this statement is misleading as it appears that 120 sessions from each participant was studied. Please be more specific that it was 10 per participant and 120 in total.

2. Please use statistical values wherever appropriate when elaborating results. If not statistically significant – please state so.

INTRODUCTION:

1. Page 3, Line 56-58: The authors state that “the considerable unexplained heterogeneity” – the authors have not raised this issue nor are there references to this statement. Please consider identifying key references that support this statement and include a few lines summary to substantiate this statement since this seems to form the central theme of the relevance of this study.

MATERIALS AND METHODS:

1. How was the sample size arrived at? Was this study adequately powered? Please provide information on power calculation

2. Why only 10 out of 50 sessions were used? How were they randomly selected?

3. It is not clear how duration for each sextant surface that was brushed was observed and calculated – please clarify.

4. Were these participants already using electric toothbrushes before? Were they provided any information of how to use them? Did they have any dental diseases? Please include this information as it is pertinent to the study.

5. Although the statistical methods used are described in sufficient detail, the outcome of the analysis is lacking in the paper and are not presented in the appropriate locations to substantiate the important results and conclusions.

RESULTS:

1. Page 8, 9, Line 167- 172: No statistical values are reported to substantiate statements like “substantial variation”. Also, the authors state “estimated variability” – were they not directly measured?

2. Page 9, Line 189-191: No statistical values are reported to substantiate statements.

3. Page 10, Line 196-199: No statistical values are reported to substantiate statements.

DISCUSSION:

1. Page 11, Line 220-222: The authors state “Our study showed that electric toothbrushes are not used optimally for plaque removal.” Plaque removal was not measured as part of this study and this line would be an extrapolation of the results that is best avoided.

2. There are some redundant sentences in the discussion. Specifically, Page 10, 11 Lines 210 – 212 and Page 11 Line 224-225.

3. Page 12, Line 249, 251: Was the high criterion validity measured by the authors in this study?

4. Page 13, Line 260-263: The authors state “dentally aware group.” Please clarify the nature of this population.

FIGURES AND GRAPHS:

Figures requires titles and footnotes.

Reviewer #2: Well constructed study.

1. Please be consistent between the terms "electric" and "powered".

2.Age range and gender have not been mentioned in materials and methods.

3. Why were the participants not given the manufacturer's brushing instructions?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2022 May 19;17(5):e0263638. doi: 10.1371/journal.pone.0263638.r002

Author response to Decision Letter 0

18 Mar 2022

A naturalistic study of brushing patterns using electric toothbrushes

Essalat, Morrison, Kak, Chang, Roig, Kulchar, Padilla, Shetty

[PONE-D-22-02067] - [EMID:48f78bddccdd4d40]

Responses to the reviewers’ comments

Dear Editor,

Please find enclosed our revised manuscript. We are heartened that our submission was resonant with the reviewers and thank them for their constructive comments. Where appropriate, we have revised the manuscript accordingly and provide our specific responses below.

Reviewer #1 comments:

the study does not appear to provide sufficient aggregated statistical data (although it appears that it was done) to substantiate the results and conclusions from the study. The study also might be under powered with only 12 participants (the authors have not provided how the sample size was arrived at).

We have added a paragraph in materials and methods to clarify this point. Specifically, our observational study was not designed to detect a predetermined difference in measurement between two groups (power). The focus of our study was on clarifying individual differences in terms of toothbrushing duration, dental regions covered, and episodes of excessive brushing pressure in each dental region.

The authors use the word electric toothbrushes throughout the study (and title). Since the type of toothbrush studied here was only of the rotation oscillation type, it cannot be generalized to all types of electric toothbrushes. The authors need to use more specific language across the full text and title to correctly represent what is being studied.

As suggested, we have changed replace the term” electric” with the more appropriate “powered” toothbrush through the revised manuscript.

In addition, it appears that the participants were video recorded during all sessions of tooth brushing (needs clarification from authors). Although it might be closer to their natural home practices than studying it in a professional setting, it still does not fully resemble a naturalistic brushing pattern. Consider rewording the title and abstract/full text information to “at home” rather than naturalistic.

While this may be a matter of semantics, naturalistic is the term more commonly used in mHealth research to describe data collected in the natural environments. The “at-home” may be a misnomer in the case of our student participants who conducted the brushing sessions in their student residences/dorms.

ABSTRACT:

1. Abstract states “analysis of brushing patterns from 120 sessions” – this statement is misleading as it appears that 120 sessions from each participant was studied. Please be more specific that it was 10 per participant and 120 in total.

As suggested, we have corrected that statement to “total 120 sessions” and clarified through greater specificity of the language (10 sessions per participant and 120 in total).

2. Please use statistical values wherever appropriate when elaborating results. If not statistically significant – please state so.

As suggested, we have added the p-values and confidence intervals.

INTRODUCTION:

1. Page 3, Line 56-58: The authors state that “the considerable unexplained heterogeneity” – the authors have not raised this issue nor are there any references to this statement. Please consider identifying key references that support this statement and include a few lines summary to substantiate this statement since this seems to form the central theme of the relevance of this study.

As suggested, we have improved the explanation and added the corresponding reference. Specifically, we now state “The considerable heterogeneity in plaque removal with powered toothbrushes (I(2) > 80%) observed in [5], could not be explained by the difference in types of powered toothbrushes, and may more likely be explained by varying toothbrushing patterns.

MATERIALS AND METHODS:

1. How was the sample size arrived at? Was this study adequately powered? Please provide information on power calculation

We used convenience sampling for our study that utilized repeated measures. The sample size was based on previous studies [1, 2] which had recruited 12, 10, and 12 subjects. Given the observational nature of the study of individual differences, no power calculation was performed. We submit that our use of confidence intervals and p-values are sufficient to identify trends and results that were statistically significant.

2. Why only 10 out of 50 sessions were used? How were they randomly selected?

Annotating videos for machine learning purposes is a very time and resource intensive task. For elucidating individual variability, we choose to focus on annotating 10 sessions out of the of 50 sessions provided by each participant. The sessions for annotation were selected randomly with each brushing session having an equal chance of being selected. The “Data Processing and Annotation” subsection has been updated to reflect this point.

3. It is not clear how duration for each sextant surface that was brushed was observed and calculated – please clarify.

The revised “Data Processing and Annotation” subsection clarifies this now. Specifically, “Every epoch of brushing a dental region that lasted more than 0.5 second was annotated by marking the beginning and end timestamp of that brushing epoch.”

4. Were these participants already using electric toothbrushes before? Were they provided any information of how to use them? Did they have any dental diseases? Please include this information as it is pertinent to the study.

As the text clarifies, the participants were young healthy college students with no dental disease. None had prior experience with powered toothbrushes. Basic instruction on the use of the brush and setting up the data collection system was given and then the participants were instructed to freely brush their teeth in a manner most natural to them (i.e., no structure brushing patterns, such as the Bass method, were prescribed).

5. Although the statistical methods used are described in sufficient detail, the outcome of the analysis is lacking in the paper and are not presented in the appropriate locations to substantiate the important results and conclusions.

As suggested, we have amplified on this in greater detail now (also see response to comment 1 above)

RESULTS:

1. Page 8, 9, Line 167- 172: No statistical values are reported to substantiate statements like “substantial variation”. Also, the authors state “estimated variability” – were they not directly measured?

We added the coefficient of variation and consider it to be substantial since it is larger than 5%. Also, we added this to the section A3 in the supplementary file. We changed the term “estimated” to “observed” since it is empirically measured.

2. Page 9, Line 189-191: No statistical values are reported to substantiate statements.

We have now included the coefficient of variations for all the regions brushed by all the participants in the supplementary file subsection A2.2. We now state that: “Coefficient of variation for all the regions that were brushed during a brushing session was greater than 20%. (See S1 Appendix A2). “

Also, we now included the p-value and confidence intervals for the claimed observations.

DISCUSSION:

1. Page 11, Line 220-222: The authors state “Our study showed that electric toothbrushes are not used optimally for plaque removal.” Plaque removal was not measured as part of this study and this line would be an extrapolation of the results that is best avoided.

We agree and have removed that sentence.

2. There are some redundant sentences in the discussion. Specifically, Page 10, 11 Lines 210 – 212 and Page 11 Line 224-225.

We removed the redundancies.

3. Page 12, Line 249, 251: Was the high criterion validity measured by the authors in this study?

We have removed that sentence.

4. Page 13, Line 260-263: The authors state “dentally aware group.” Please clarify the nature of this population.

We have now clarified them as college students.

FIGURES AND GRAPHS:

Figures requires titles and footnotes.

We were following PLOS ONE guidelines that instruct authors, “Do not include author names, article title, or figure number/title/caption within figure files. That information will go into your figure caption in the manuscript.”

Reviewer #2 comments:

1. Please be consistent between the terms "electric" and "powered".

As suggested, electric has been replaced with powered.

2. Age range and gender have not been mentioned in materials and methods.

This is now included in the Materials and Methods section.

3. Why were the participants not given the manufacturer's brushing instructions?

There are no specific manufacturers’ instructions. However, participants were instructed on how to set up the brush and data collection equipment- they then brushed using their natural preferences. Details are now provided in the Materials and Methods section.

References:

[1] Huang H, Lin S. Toothbrushing monitoring using wrist watch. In Proceedings of the 14th ACM Conference on Embedded Network Sensor Systems CD-ROM 2016 Nov 14 (pp. 202-215).

[2] Luo C, Feng X, Chen J, Li J, Xu W, Li W, Zhang L, Tari Z, Zomaya AY. Brush like a dentist: accurate monitoring of toothbrushing via wrist-worn gesture sensing. In IEEE INFOCOM 2019-IEEE Conference on Computer Communications 2019 Apr 29 (pp. 1234-1242). IEEE.

[3] Lee YJ, Lee PJ, Kim KS, Park W, Kim KD, Hwang D, Lee JW. Toothbrushing region detection using three-axis accelerometer and magnetic sensor. IEEE Transactions on Biomedical Engineering. 2011 Dec 22;59(3):872-81.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (23.8KB, docx)

Decision Letter 1

Tanay Chaubal

5 Apr 2022

PONE-D-22-02067R1A naturalistic study of brushing patterns using powered toothbrushesPLOS ONE

Dear Dr. Mahmoud Essalat,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================Kindly address the comments mentioned by the reviewers.

==============================

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We look forward to receiving your revised manuscript.

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Tanay Chaubal

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Some comment(s) have not been addressed (the comment says it has been).

Specifically:

1. There are some redundant sentences in the discussion. Specifically, Page 10, 11

Lines 210 – 212 and Page 11 Line 224-225.

Reviewer #2: Well written manuscript. suitable for acceptance. the concept of the manuscript is novel and gives an insight into the brushing pattern of subjects who have had no directions on how to brush.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PLoS One. 2022 May 19;17(5):e0263638. doi: 10.1371/journal.pone.0263638.r004

Author response to Decision Letter 1

12 Apr 2022

Dear Editor,

I am delighted to learn the favorable reaction of the reviewers.

Allow me to clarify the residual issue of redundant sentences (Critique 6- Reviewer 1).

There are some redundant sentences in the discussion. Specifically, Page 10, 11

Lines 210 – 212 and Page 11 Line 224-225.

In writing the discussion, we followed the general guidelines provided by PLOS (https://plos.org/resource/how-to-write-conclusions/).

The first paragraph of the discussion section provides a high-level summary of our main findings. The subsequent paragraphs begin with a brief description of each finding, followed by a brief interpretation of the finding and a comparison/contrast with findings by other investigators.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (18.3KB, docx)

Decision Letter 2

Tanay Chaubal

4 May 2022

A naturalistic study of brushing patterns using powered toothbrushes

PONE-D-22-02067R2

Dear Dr. Mahmoud Essalat,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Tanay Chaubal

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

**********

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Reviewer #1: No

Acceptance letter

Tanay Chaubal

11 May 2022

PONE-D-22-02067R2

A naturalistic study of brushing patterns using powered toothbrushes

Dear Dr. Essalat:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Tanay Chaubal

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Appendix. Statistical analysis.

    (DOCX)

    Click here for additional data file. (212.5KB, docx)
    Attachment

    Submitted filename: Response to reviewers.docx

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    Attachment

    Submitted filename: Response to reviewers.docx

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    Data Availability Statement

    The dataset used as well as the code to generate the results are publicly available publicly at a GitHub repository. Essalat, M., & Morrison, D. (2022). Brushing-Behavior (Version 1.0.0) [Computer software]. https://doi.org/10.5281/zenodo.1234.

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