한연구는많이존재하지만, 저연령대어린이를대상으로진행된연구는매우드물다. 따라서본연구에서는 3-6세어린이들을대상으로음파칫솔과일반칫솔을사용했을때구강위생상태를 Löe & Silness 치태지수로측정, 비교하여저연령대어린이에서음파칫솔의치태제거효과에대해알아보고자한다. Ⅱ. 연구대상

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ISSN (print) 1226-8496 ISSN (online) 2288-3819 http://dx.doi.org/10.5933/jkapd.2016.43.4.374 Effectiveness of Sonic and Manual Toothbrush in Preschool Children Youngseob Shin 1, Hyoseol Lee 2, Jeseon Song 1, Jaeho Lee 1 1 Department of Pediatric Dentistry, College of Dentistry, Yonsei University 2 Department of Pediatric Dentistry, College of Dentistry, Kyunghee University Abstract The purpose of this study is to compare the effectiveness of sonic and manual toothbrushes using the Löe and Silness plaque index (PI). This was an examiner-blind, randomized study with a cross-over design. A total of 34 children (17 males and 17 females) aged 3-6 years were included. Subjects were randomly assigned to two groups: one group used the sonic brush for two weeks before using the manual brush for two weeks, while the other group used the manual brush for two weeks followed by the sonic brush. During each dental visit, plaque indices were recorded and compared to baseline. The results were analyzed using a paired t-test or Pearson correlation test (α= 0.05). Thirty children (mean age 4.37 years) complied with the protocol and completed the study. The PI score was 0.09 lower compared to baseline after using a manual toothbrush and 0.26 lower after using the sonic brush. The reduction was statistically significantly greater in the sonic group (p < 0.05). In conclusion, the sonic toothbrush is more effective for reducing plaque than a manual toothbrush. Key words : Sonic toothbrush, Power toothbrush, Toothbrushing, Dental devices, Preventive dentistry, Children Ⅰ. 서론치태는치은염 (gingivitis) 혹은치아우식 (dental caries) 에영향을줄수있기때문에구강건강의유지를위해서는양치질을통한치태의제거및관리가필수적이다 1-3). 효율적인치태제거를위해서는양치질횟수, 시간, 방법등의여러가지변수를고려할수있지만, Habibian 등 4) 은치면세균막의제거정도에있어서양치질횟수는관련이없고정확한양치방법이더중요하다고보고하였다. 하지만저연령대의어린이의경우동기부여및손기술의발달부족으로인해양치질에어려움을겪는다 5). 이러한점의개선을위해어린이들의관심을유도하고효과적으로치태제거가가능한일반칫솔이나전동칫솔등의많은구강위생용품이개발되었는데, 이중전동칫솔은호기심 을유발하고사용시즐거움을주기때문에어린이들에게선호된다 6,7). 전동칫솔은 1960년대초반에처음으로상업적으로소개되기시작했고 8-11), 현재는양치질이어려운장애인뿐만아니라일반성인과어린이를대상으로다양한종류의제품이판매되고있다. 전동칫솔은동작방법에따라 side to side, counter oscillation, rotation oscillation, circular, ultrasonic, ionic, unknown action 으로분류되는데 12), 초기시판된전동칫솔은 back and forth 등의한정된움직임을보였지만현재는 oscillating-rotating과 ultrasonic 등의여러종류의다양한움직임을보이는전동칫솔이개발되었다. 성인을대상으로치태지수나치은지수등을이용하여전동칫솔과일반칫솔, 혹은전동칫솔의종류에따른효과를비교 Corresponding author : Jaeho Lee Department of Pediatric Dentistry, College of Dentistry, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea Tel: +82-2-2228-3170 / Fax: +82-2-392-7420 / E-mail: leejh@yuhs.ac Received November 9, 2015 / Revised January 25, 2016 / Accepted December 23, 2015 The authors deny any conflicts of interest related to this study. 374

한연구는많이존재하지만, 저연령대어린이를대상으로진행된연구는매우드물다. 따라서본연구에서는 3-6세어린이들을대상으로음파칫솔과일반칫솔을사용했을때구강위생상태를 Löe & Silness 치태지수로측정, 비교하여저연령대어린이에서음파칫솔의치태제거효과에대해알아보고자한다. Ⅱ. 연구대상및방법본연구는 2014년 6월부터 2015년 5월까지연세대학교치과대학기관윤리위원회로부터승인 (2-2014-0027) 과환자및보호자의동의하에이루어졌고, 총 34명의어린이들이참여하였다. 1. 연구대상연세대학교치과대학병원소아치과에내원한신체적, 정신적으로건강한 3-6세어린이들을대상으로하였고, 우식치료가필요하거나구강병소, 심한전신질환혹은구강위생용품에부작용이있는어린이는제외되었다. 연구참여자에대한선별기준은 Table 1에나타나있다. 2. 연구방법본연구는교차설계 (cross-over design), 연구자에대한눈가림법을사용한무작위대조군연구로음파칫솔 (Philips Sonicare For Kids, Philips, 네덜란드 ) 과일반칫솔 (Oral-B Pro-Health Stages 2 or 3, Oral-B, 미국 ) 이참여자에게각각 1개씩지급되었다. Philips Sonicare For Kids는 5Hz의주파수로, 분당 600회의칫솔모진동을하며좌우 7도 ( 저속모드 ) 혹은 9도 ( 고속모드 ) 의진폭을가진다. 연구참여자들은난수표를사용하여 1군과 2군으로무작위로나누어지고 2주간격으로총 4번내원하였는데, 1군은음파칫솔, 시차 (wash-out time), 일반칫솔순으로, 2군은일반칫솔, 시차, 음파칫솔순으로진행되었다 (Fig. 1). 첫번째, 세번째내원시 2주간사용할칫솔제공과해당칫솔에대한구강위생교육이진행되었고, 일반칫솔은묘원법, 음파칫솔은제조사에서제시한방법, 시차기간에는연구참여전사용하던칫솔및양치질방법으로하루 2번, 2분씩양치할것이설명되었다. 연구참여기간동안, 제공받은칫솔을제외한다른구강위생용품사용은금지되었고, 내원전양치한이후에는음식섭취하지않고올것이설명되었다. Table 1. Inclusion and exclusion criteria Inclusion criteria Exclusion criteria 1. 3-6 year old 1. Children who need special dental care 2. Without systemic disease 2. With systemic disease 3. Children who brush their own teeth or whose brushing is aided by their parents 3. With oral lesions 4. Children who agreed to the experiment conditions 4. With side effects from oral hygiene products Fig. 1. Flow chart of the study. Subjects were randomly assigned to two groups: one group used the sonic brush for two weeks before using the manual brush for two weeks, while the other group used the manual brush for two weeks followed by the sonic brush. There was a 2-week wash-out between the two periods. 375

3. 구강위생상태검사 5. 통계분석 매내원시마다 Löe & Silness 치태지수와 Quantitative Light induced Fluorescence-Digital (QLF-D) 이동일한연구자에의해기록및촬영되었다. 치태제거정도를비교하기위해본연구에서사용한 Löe & Silness 치태지수는다음과같다 (Table 2). 이방법에따라각치아당 4군데 ( 근심협측, 협측, 원심협측, 설측 ) 의치태지수가기록되었다. 치태지수의평가및기록은연구자간오차를줄이기위해동일한연구자가시행하였고, 연구전치태지수계측방법에대한사전교육및예비조사가시행되었다. 예비조사는 30명의어린이들을대상으로치태지수를무작위로 2번씩반복계측하는방법으로진행되었고, 본연구에서연구자내상관계수는 0.9 였다. 구강상태를기록하고치태지수와비교하기위해 QLF-D가촬영되었다 (Fig. 2). 1명의연구자가매번동일한장비와기준값, 환경에서측정하였고, 일정한조명하에서디지털카메라 (EOS550D; Canon, Tokyo, Japan), 마크로렌즈 (EF-S 60mm Ultrasonic; Canon), 520 nm 황색필터를사용하여셔터스피드, 조리개, ISO 감도그리고화이트밸러스일반으로설정하여촬영하였다. 4. 설문조사음파칫솔사용전과후에보호자들을대상으로설문조사가진행되었고, 연구참여기간동안보호자가기록한양치질시행횟수및양치시보호자동반여부에대한기록지가함께제출되었다. 통계분석은 IBM SPSS Statistics version 19 (IBM, Armonk, NY, USA) 를이용하였고, 음파칫솔과일반칫솔각각의치태제거효과와성별에따른치태제거효과비교시 paired T-test를, 연령에따른연관성분석시 Pearson correlation test를사용하였다. 또한교차설계로연구가진행되었기때문에음파칫솔과일반칫솔의효과비교시처치효과 (treatment effect) 와잔류효과 (periodic effect) 로나누어분석하였고, 유의수준 5% 에서검정하였다. Ⅲ. 연구성적연구에참여한 34명의어린이들중 30명이연구에최종적으로참여했다 (Table 3). 참여도중중단한 4명중 3명은협조도부족, 1명은음파칫솔사용시불편감이이유였다. 연구참여자들의평균나이는 4.37 ± 1.17세였고, 1군은 4.2 ± 0.98세, 2군은 4.53 ± 0.31세였다. 성비는남자 16명 (53.3%), 여자 14명 (46.7%) 로집단내남녀성별차이는거의존재하지않았다. 음파칫솔과일반칫솔의치태지수감소량은처치효과와잔류효과로나누어분석되었는데, 음파칫솔사용시치태지수감소량 (0.26) 과일반칫솔의사용시치태지수감소량 (0.09) 은처치효과측면에서는통계적으로유의한차이를보인반면 (p < 0.05) (Fig. 3), 잔류효과측면에서는통계적으로유의한차이를보이지않았다 (p > 0.05). 연령별비교에서음파칫솔이모든연령대에서일반칫솔보다치태제거효과가크게나타났다. 음파칫솔과일반칫솔의 Table 2. Löe & Silness Plaque Index Score Criteria 0 No plaque 1 A film of plaque adhering to the free gingival margin and adjacent area of the tooth, which can only be detected using disclosing solution or a probe. 2 Moderate accumulation of deposits within the gingival pocket, on the gingival margin and/or adjacent to the tooth surface, which is visible by eye. 3 Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin. Fig. 2. White light image and quantitative light induced fluorescence-digital (QLF-D) fluorescence image. (A) Intra-oral frontal view under white light. (B) Intra-oral frontal view under QLF-D. White arrows indicate plaque-accumulated areas. 376

Table 3. Demographics of participants All Group 1 Group 2 Participants (n) 30 15 15 Mean Age (years) 4.37 ± 1.17 4.2 ± 0.98 4.53 ± 0.31 Female (n, %) 16 (53.3%) 7 (46.7%) 9 (60%) Male (n, %) 14 (46.7%) 8 (53.3%) 6 (40%) Reduction in PI (Sonic toothbrush) 0.26 ± 0.28 0.19 ± 0.27 0.33 ± 0.27 Reduction in PI (Manual toothbrush) 0.09 ± 0.22 0.15 ± 0.20 0.03 ± 0.22 Fig. 3. Comparison of plaque removal using a manual toothbrush versus a sonic toothbrush. A statistically significant difference was observed in the degree of plaque reduction between the methods. Paired T-test (* : p < 0.05). Fig, 4. Comparison of plaque removal by age. The correlation between age and the level of plaque removal was not statistically significant. Pearson correlation test (* : p < 0.05). PI = plaque index. 치태제거효과의차이는 3세, 6세, 5세, 4세순서로크게나타났지만, 나이에따른통계적인유의차는관찰되지않았다 (p > 0.05) (Fig. 4). 성별에따른비교에서성별에관계없이모두음파칫솔이일반칫솔보다치태제거효과가좋은것으로나타났고, 여자보다남자어린이에서치태제거효과가더컸지만통계적인유의차는관찰되지않았다 (p > 0.05). 설문조사에서는다음과같은결과가나타났다 (Table 4, 5). 음파칫솔사용전어린이들의평균양치시간은 1.57분이었지만, 사용후에는평균 2.19분으로기존보다양치시간이증가하였다. 또한음파칫솔사용전권장시간인 2분이상양치하는어린이는 20% 였지만, 사용후에는 2분이상사용하는어린이들의비율이 66.7% 로증가했다. 불편감에대해서는음파칫솔사용시 60% 가불편감을느끼지못했고, 36.7% 는약간의불편감, 그리고 3.3% 가심한불편감을느꼈다. Table 4. Time spent brushing teeth before and after using the sonic toothbrush < 1 minute 1-2 minutes 2-3 minutes > 3 minutes Before using 5 19 5 1 sonic toothbrush (16.7%) (63.3%) (16.7%) (3.3%) After using 0 10 19 1 sonic toothbrush (0%) (33.3%) (63.3%) (3.3%) Table 5. Survey after using the sonic toothbrush Question Answer Convenience Yes No difference No 23 (76.7%) 4 (13.3%) 3 (10%) Tooth Cleanliness Yes No 24 (80%) 6 (20%) Time required Faster No difference Slower 16 (53.3%) 6 (20%) 8 (26.7%) Discomfort Very Slightly Comfortable uncomfortable uncomfortable 1 (3.3%) 11 (36.7%) 18 (60%) 377

Ⅳ. 총괄및고찰본연구에서 3-6세어린이들은일반칫솔에비해음파칫솔에서더욱좋은치태제거효과를보였다. 이는음파칫솔이흥미를유발해양치질에대한동기부여를주고 6,7), 참여자들의미숙한양치질을보완해주었으며, 타이머로인해양치시간이증가하였기때문으로보인다. 양치질의효과를확인할수있는지표중하나인치태제거량은양치시간과직접적으로연관되어있는데 13,14), 칫솔질교육을받지않는사람을대상으로조사했을때성인과어린이모두평균양치질시간은 1분이하라고알려져있다 15,16). Van der Weijden 등 14) 은어린이에서적절한양치시간은 2분이라고제시했고, 음파칫솔의경우 2분으로설정된타이머가있어일반칫솔에비해시간을더잘지킬수있기때문에보다좋은치태제거효과가나타난것으로보인다 17). 하지만연구에참여하면서평소와는다른행동을하는 Hawthorne 효과 18) 나처음사용하는전동칫솔이동기부여와제품사용에대한의지를일시적으로강화하는 신기성효과 19) 등으로인해음파칫솔사용시에더좋은치태제거효과가나타났을수있기때문에이런변수에대한고려가필요하다. 나이혹은성별에따른비교에서는통계적으로유의미한차이가나타나지않았다. 연구대상으로설정된 3-6세어린이들은부모님의도움없이는양치질을완벽하게하기힘든데, 이는주의력과손기술발달부족으로인한미숙한칫솔질때문이다 20). 주의력및손기술은나이가증가함에따라발달한다는점을고려했을때나이가어릴수록음파칫솔의치태제거효과가더클것이라는가설을세울수있었는데, 본연구의결과와는일치하는않다. 하지만본연구에서의표본수가 30명으로적고, 연구참여자의칫솔질시보호자가도와준경우도있기때문에환아혼자칫솔질하는것으로변수를통제하고보다많은수의표본을대상으로추가적인연구를진행한다면유의미한결과가나올수있을것으로보인다. 본연구는교차설계로진행되었는데, 다른계획에비해절반의인원만으로도시행이가능하다는장점이있는반면, 첫번째시행의효과가지속되어두번째시행시결과에영향을미치는잔류효과가발생할가능성이있다는단점이있다. 잔류효과를줄이기위해연구도중에 2주간의시차를두었고, 통계분석결과처치효과는통계적으로유의미했지만잔류효과는유의미하지않았는데, 이를통해해당연구에서교차설계의단점중하나인잔류효과없이적은표본수를보완하는결과를얻었음을확인할수있다. 칫솔의종류에따른치태제거혹은치은염감소효과에대한연구에서는다양한결과가나타난다 12,21-27). 전동칫솔과일반칫솔의효과비교에대한메타분석연구에서 oscillated rotating 전동칫솔만이일반칫솔에비해통계적으로유의미하게효과가있고다른종류의전동칫솔은통계적으로유의미한효과차이가없다고보고하였고 12), 전동칫솔의종류에따른치태제거효과및치은염감소효과를비교한 Deacon 등 28) 의메타분석 에서는 oscillated rotating 전동칫솔이 side to side 전동칫솔에비해단기간에는더효과가있지만차이가작고임상적중요도에대한판단이불확실하다고하였다. Philips Sonicare For Kids는 side to side 전동칫솔로메타연구에서 rotation oscillation 전동칫솔에비해우세한효과가입증되지는않았지만, 본연구에서는기존메타연구결과와는다르게일반칫솔에비해더좋은효과를보였다. 이런다른결과가나온것은새로운음파칫솔에대해진행된비교연구가아직많지않아기존메타분석에적게포함되었기때문인것으로보이고, 학령기전어린이를대상으로진행된소수의연구에서전동칫솔이일반칫솔에비해더좋은치태제거효과를나타낸다는보고가있었기때문에 29,30) 이러한학령기전어린이를대상으로한음파칫솔에대한추가적인비교연구가필요할것으로보인다. 음파칫솔에대한설문조사결과, 60% 는불편감이없었지만 36.7% 는약간의불편감, 3.3% 는심한불편감을호소했다. 특히참여자중 1명은연구참여를중단했는데, 이는음파칫솔사용시진동에대한불편감때문이었다. 기존저연령대어린이를대상으로한연구에서전동칫솔사용시불편감에대해조사한문헌은없지만학령기전어린이의양치질에있어서중요한점중하나는동기부여이다 29). 어린이의부족한양치질숙련도를보상해주는일반칫솔이보편적으로사용되고전동칫솔과비슷한치태제거효과를나타내고있기때문에 31) 음파칫솔사용에불편감이심한경우일반칫솔등의다른구강위생용품을사용한관리가추천되고, 또한음파칫솔사용시거부감을줄이고어린이가보다호의적으로접할수있도록사용법에대한치과의사와부모님의자세한설명과접근이필요하다. 참여자표본수가 30명으로적다는점과구강위생교육시설명한양치횟수나시간, 그리고양치질시부모님동반여부등에대한변수통제가어린이집이나유치원에서하는양치등의이유로완전히이루어지지못한점은이연구의한계점이라고할수있다. 따라서변수를보다철저히통제하고, 더많은참여자를대상으로추가적인연구가필요할것으로사료된다. Ⅴ. 결론본연구에서전신질환이없는 3-6세어린이 30명을대상으로음파칫솔과일반칫솔의치태제거효과를비교 분석하여다음과같은결론을얻었다. 3-6세어린이에서음파칫솔의치태제거효과는일반칫솔의치태제거효과보다컸고 (p < 0.05), 성별및연령에따른치태제거효과는음파칫솔및일반칫솔모두에서차이가없었다 (p > 0.05). References 1. Farina R, Tomasi C, Trombelli L : The bleeding site: a multi-level analysis of associated factors. J Clin Periodontol, 40:735-742, 2013. 2. Zenkner JE, Alves LS, de Oliveira RS, et al. : 378

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국문초록 미취학어린이에서음파칫솔과일반칫솔의효과 신영섭 1 이효설 2 송제선 1 이제호 1 1 연세대학교치과대학소아치과학교실 2 경희대학교치의학전문대학원소아치과학교실 본연구의목적은 Löe & Silness의치태지수를사용하여음파칫솔과일반칫솔의효과를비교하는것이다. 연세대학교치과대학병원소아치과에내원한전신질환이없는 3-6세어린이 34명을대상으로교차설계, 연구자에대한눈가림법을사용한무작위대조군연구가진행되었다. 연구참여자는 2개의군으로무작위로나누어져음파칫솔과일반칫솔을번갈아 2주씩사용하였고, 칫솔질전후구강위생상태를 Löe & Silness의치태지수를사용하여측정하여차이를비교하였다. 음파칫솔사용후 0.26 ± 0.28, 일반칫솔사용후 0.09 ± 0.22의치태지수감소를보였고, 이는통계학적으로유의한차이를보였다 (p < 0.05). 성별과나이에따른음파칫솔의치태제거효과는통계학적으로유의한차이를보이지않았다 (p > 0.05). 연구결과, 3-6세어린이에서음파칫솔이일반칫솔에비해치태제거효과는좋았고, 성별과연령에따른치태제거효과의차이는나타나지않았다. 주요어 : 음파칫솔, 전동칫솔, 칫솔질, 치과장비, 예방치과, 어린이 381