JIDAM

ORIGINAL ARTICLE

eISSN 2582 - 0559

Available online

EVALUATION

OF MOBILE DENTAL

APPLICATIONS

USING USER VERSION

MOBILE

APP RATING SCALE (uMARS)

.Parvathy Thampy. P.S, Dr.Nijesh. J. E, Dr.Preetha Elizabeth Chaly, Dr.Shyam. S,

Dr.Vaishnavi.S.

Department

of Public Health Dentistry,

Faculty

of Dentistry, Meenakshi Academy of Higher Education and Research Institute, Chennai, Tamil Nadu,

India.

ABSTRACT

To access & cite this article

Website: jidam.idamadras.com

Address for correspondence:

Nijesh. J. E., MDS.,

Assoc

Professor, Department of Public Health Dentistry

Meenakshi

Ammal Dental College and Hospital, Chennai

id: dr.j.e.nijesh@gmail.com

Received – 17.01.2020
Accepted – 18.02.2020
Published – 27.03.2020

PURPOSE

: The use of mobile phone applications (Apps)

has the potential to revolutionize the conventional practice of

dentistry. There is a remarkable proliferation of mobile

health apps in the field of dentistry which necessitates an

urgent and reliable evaluation of the quality of these apps.

The main objective of the article is to analyze the quality of

dental apps using a reliable tool.

METHOD

: A systematic search was conducted on

SamsungJ7 Prime and iPhone 7 using Google Play Store and

App store respectively from June to August 2017 using the

search terms “oral hygiene”, “tooth brushing”, oral health

education”, ‘baby teeth care”. After due application of a pre-

determined selection criteria, twenty dental apps were

randomly

selected

using

computer

software

(www.randomizer.com). Each app was individually assessed

and rated (1- inadequate, 2- poor, 3- acceptable, 4- good, 5-

excellent) according to a prevalidated user version of Mobile

App Rating Scale (uMARS).

RESULT

: The rating of dental apps used in this study

ranged from 1.08/5 to 3.25/5. According to the objective

criteria of uMARS, apps such as Brush DJ and Brush Up

were found acceptable. Teeth Care Tips, Dental Surgery

Simulator, Dental Expert and UC Dental were scored

acceptable along with the former two apps under subjective

criteria.

CONCLUSION

: No apps scored good or excellent as per

the uMARS criteria. As advances in technology have

promoted the use of smart devices in health promotion and

practices medical or dental apps must not only be

informative and entertaining but also be evidence based and

scientifically rated.

KEYWORDS

: mHealth, Smartphones, Oral health, Mobile

application, rating.

JIDAM/Volume:7/Issue:1/Pages1 - 7/January - March 2020

DOI:10.37841/jidam_2020_v7_i1_02

Parvathy et al: Mobile dental apps and uMARS

JIDAM/Volume: 7/Issue: 1/Pages 1 - 7/January - March2020

INTRODUCTION

A mobile medical or dental app is a software

application used on a mobile device for medical, dental or

other health-related purposes. The wireless technology usage

to deliver health services and information on mobile

communication devices such as mobile phones, personal

digital assistants, smartphones, monitoring devices, e-book

readers, iPod and smart watches is known by the term

mobile health or m-health.

Mobile phones are an attractive

platform for delivering remote patient monitoring services.

In recent years, many researchers have employed mobile

phones as tools for monitoring symptoms in heart diseases,

diabetes and other chronic diseases.

Smartphone ownership

and internet usage continues to climb in emerging economies.

According to PwC’s Global Entertainment and Media

Outlook 2019–2023, the number of smartphones in India has

risen by more than 280% in the past five years, to 600mn in

2018.

mHealth is one of the largest sectors within Digital

Health Care in India, with an estimated market size of 2,083

crore INR in 2015 which is set to rise to 5,184 crore INR by

2020.

Patients today are more conscious, tech-savvy and

more willing to embrace emerging technologies.

For ease of

access and cost savings, the Indian population is readily

adopting technology such as virtual medicine and health

services apps due to high mobile penetration and a heavy

share of the healthcare costs. There are now over 318,000

health apps available on the top app stores worldwide, nearly

double the number of apps available in 2015 – with more

than 200 apps being added each day.

The top two categories

among them are wellness management and disease

management apps like

diabetes, asthma, cardiac

rehabilitation and pulmonary rehabilitation. The global

mHealth app market is projected to be valued at US$28.320

billion in 2018 and is expected to reach up to US$102.35

billion by 2023

. The major driving factors fueling growth of

the mHealth market is the increased adoption of smartphones,

as well as the continued heavy investment into the digital

health market. People desire more control of their health and

are open to new ways of receiving care. However, the

accuracy of the health information contained in most of these

apps is not scrutinized by regulatory bodies, which could

compromise user’s health and safety.

According to the Global Burden of Disease study

done between 1990 and 2010 focusing on 291 conditions,

3.9 billion people worldwide were affected with oral

diseases. Untreated caries in permanent teeth affected 35%

of the population whereas severe periodontal diseases,

untreated caries in primary teeth and severe tooth loss

affected 11%, 9% and 22% of global population

respectively.

Lack of perceived oral health needs among

public is a major barrier to oral health care. A cross sectional

qualitative research have shown that mobile applications are

a promising tool to motivate an evidence based oral hygiene

routine.

Due to rapid proliferation of smartphone apps, it is

difficult for end users to identify and access the right health

apps. Little information is available

beyond the star ratings which are published on the retailer

web page. The star rating ranges from one to five, with one

star denoting extreme dissatisfaction with an app and five

stars denoting high satisfaction. The review comments and

star ratings are the factors on which the downloads of an app

are based. This rating reflects only the experience of the user

with the app and is inconsistent.

There is no scientific study conducted to assess the

quality of the dental apps available. As a result, a sincere

effort was made to evaluate the quality of existing mobile

dental health apps using a pre validated tool - user version of

Mobile App Rating Scale which is reliable for assessing the

quality of mobile health apps

METHODOLOGY

A cross sectional study was initiated in the

Department of Public Health Dentistry, for which a

comprehensive App search was conducted in June 2017 with

a completed updated search in August 2017, using Google

Play store (SamsungJ7 Prime) and Appstore (iPhone 7). The

search terms “oral hygiene”, “tooth brushing”, oral health

education”, ‘baby teeth care” was used. All freely

downloadable, English language apps were included in the

study. Purely gaming, exam oriented, dental specialty apps,

dental products marketing and private clinic apps were

excluded from the sampling frame (Fig 1).

Of the

remaining 98 apps, twenty dental apps were randomly

selected by a computer software. (

www.randomizer.org

Parvathy et al: Mobile dental apps and uMARS

JIDAM/Volume: 7/Issue: 1/Pages 1 - 7/January - March2020

The selected apps were downloaded and installed in the

appropriate mobile device (Fig 2). The selected apps were

subjected to trial five times in a span of 2 weeks and were

individually assessed and rated in isolation by the authors.

Grading was performed independently by the principal

investigator according to the user version of Mobile App

Rating Scale.

The star ratings and the number of downloads

given in the publishers’ web page were also recorded.

Mobile App Rating Scale (MARS)

Mobile App Rating Scale (MARS) is an evidence

based mHealth app quality rating tool developed by Stoyan

et al in 2014.

Pretraining along with a substantial amount

of expertise in the field of mHealth is required to use it

correctly. Thus, the MARS has been simplified and modified

for end users (uMARS), to be used as a reliable tool to assess

and report the quality of mHealth apps. uMARS rates the

quality of the mobile app both objectively and subjectively

separately using 20 subcategories.

The objective criteria

measurement includes the Engagement, Functionality,

Aesthetics and Information quality of the mobile app and

each item is scored on a 5-point scale (1- inadequate, 2- poor,

3- acceptable, 4- good, 5- excellent). Mean scores instead of

total scores are used because an item can be rated as Not

applicable also. Additionally, mean scores are used for

comparing with corresponding star ratings. Objective Quality

Mean Score of the mobile app is obtained by summing up

the mean scores of Engagement, Functionality, Aesthetics

and Information quality subscales. Subjective Quality Mean

Score is obtained by taking the mean of the scores obtained

for four questions under

subjective criteria (Would you recommend this app to

people who might benefit from it?, How many times do you

think you would use this app in the next 12 months if it was

relevant to you?, Would you pay for this app?, What is your

overall star rating of the app?).

RESULTS

A total of 354 dental apps were identified from

android (Samsung J7 Prime) and iOS (iphone7) platform of

which eighteen apps were common to both the platforms. A

total of ninety- eight apps (Fifty-five apps from google play

store and forty-three apps from app store) were identified

using the selection criteria (Figure 2).

Apps like Dentist Office, Brush’n’Save, Dental

Surgery Stimulator, Dental Care, Tooth Brush Timer, Brushy

time, Easy Teeth Care tips and Quick Brush-Tooth brush

timer were downloaded from Google play store. Teeth care

tips, Text 2 Floss, Dental Expert, Brushing app and Brush

teeth were retrieved from apple platform. A few apps like

Brush DJ, Brush Up, Magic Timer, My Bright Smile, UC

Dental, Family dental care, My Dental Care were present on

both the platforms. The size of the apps ranged from 2.7 to

317.9 MB. Only freely downloadable apps were considered.

Mean scores were calculated and tabulated after the authors

scored the apps for objective subscales by applying the

uMARS.

On analyzing the results none of the apps were scored

good or excellent according to uMARS criteria.

The

uMARS objective scores ranged from 1.08/5 to 3.25/5.

Brush DJ and Brush Up scored acceptable (3-4), thirteen of

them scored poor (2-3) and remaining five apps scored were

inadequate according to uMARS (Table 1). Only three out of

the twelve apps star rating, matched with the subjective

scores which shows its subjective nature. Moreover, the star

ratings given in the web page are not reliable as they come

from unknown source.

Parvathy et al: Mobile dental apps and uMARS

JIDAM/Volume: 7/Issue: 1/Pages 1 - 7/January - March2020

Table 1: Table depicts the uMARS subjective and objective mean score and star ratings of dental apps:

App Name

Developer

Star

rating

Subjective

Score

Objective score

Engagement Functionality Aesthetics Information

Quality

Mean

score

Brush DJ

Ben

Underwood

4.1

3.5

0.72

0.95

0.66

0.92

3.25

Brush Up

Big Fun

Development

3.6

3.25

0.84

0.6

0.8

0.85

3.09

Dentist

Office

Beansprites

LLC

2.5

0.44

0.73

0.72

2.89

Magic

Timer

Walt Disney

3.9

2.5

0.6

0.75

0.87

0.64

2.86

My bright

Smile

Colgate

3.8

3.25

0.52

0.9

0.6

0.67

2.68

Teeth care

tips

Rajesh Kumar -

3.25

0.44

0.9

0.67

0.65

2.66

UC Dental

Dental

Insurance Co

3.3

0.68

0.75

0.47

0.75

2.65

Dentist

Kids

3.2

0.64

0.7

0.6

0.65

2.59

Dental

Surgery

Stimulator

Zain Zafar

3.3

3.25

0.52

0.65

0.8

0.55

2.52

Text 2 Floss Arizona

School of

Dentistry and

Oral health

0.44

0.75

0.53

0.7

2.42

Family

dental care

Dr Damyokef

Belote

0.56

0.75

0.4

0.56

2.27

My Dental

Care

Dr Shivam

Divani

2.75

0.28

0.75

0.4

0.8

2.23

Dental Care MSPLD

Developers

4.6

0.6

0.5

0.6

0.52

2.22

Dental

Expert

Marc Lazare

3.5

0.4

0.65

0.4

0.75

2.2

Parvathy et al: Mobile dental apps and uMARS

JIDAM/Volume: 7/Issue: 1/Pages 1 - 7/January - March2020

Brushing

app

Singer Dental

1.5

0.36

0.8

0.33

0.66

2.15

Brush teeth

Spyridon

Bousis

1.25

0.56

0.35

0.27

0.33

1.51

Tooth

Brush

Timer

Japps Medical 4.2

0.36

0.25

0.4

0.45

1.46

Brushy time Laser Boy

1.25

0.36

0.3

0.4

0.35

1.41

Easy Teeth

Care tips

Dierre09

2.7

1.25

0.28

0.45

0.25

0.35

1.33

Quick

Brush-
Toothbrush

timer

Samy

Nakayam

Driss

3.5

1.25

0.28

0.39

0.2

0.3

1.08

DISCUSSION

Despite great improvements in oral health globally,

problems still remain in many countries all over the world.

This can be due to inequitable distribution of oral health care

services. Technology now exists to support distance

collaboration between dentists and the population. Electronic

collaborations are frequently used in medicine but have only

been slowly adopted in dentistry. Advances in technology

have promoted the use of smart devices in health promotion

and practices. Patients and the family care givers use

different patterns of information seeking like internet or free

mobile apps. Study done by Morwenna Kirwan et al showed

that an app with much higher usability, might increase usage

and maintenance of health behavior change in the long

term.

Due to this behavior, the efficiency of these must be

evaluated randomly and the general public need to be

forewarned to exercise caution when using health apps in

general.

All the available dental apps were scrutinized using

the search terms in two most popular app platforms from

June -August 2017 for this study. Three hundred fifty-four

dental apps have been retrieved. Applying the elimination

criteria, the apps were further reduced to ninety-eight apps.

Of which twenty apps were randomly selected and tested for

proper functioning. The objective and subjective quality of

these apps were assessed according to uMARS and then

compared with their star ratings in the web page. The

concurrent uMARS rating of the app when compared with

star rating given in the web page did not match which is in

line with the study conducted by Stoyan et al (2014) using

MARS on mental health apps.

Five-star ratings can be

misleading as the vast majority of the users will be the one

who always provide a positive rating as they were using it

over competitive alternatives and want to justify their

decision

. Very few in the population who had rated the apps

would have been one-time users who have conducted an

unbiased assessment of the available alternatives.

Brush DJ and Brush Up were scored acceptable (3-4).

Thirteen of them scored poor (2-3) which is in line with the

study conducted by Tiffany B et al in 2018 on oral health.

Rest of the five apps were scored as inadequate according to

uMARS. None of the apps rated Good or excellent according

to uMARS. The number of available dental apps clearly

expressed the interest of the public in experimenting with

newer technologies in the field of oral health.

Given the recent development of mHealth apps,

formal literature citing the efficacy of these apps remains

limited. This is the first study attempted to evaluate the

efficiency of dental apps scientifically. Most of the apps are

self-explanatory and do not require trained personnel for its

use. Although the reviews are performed on the App store

not all the apps are supported or verified by an international

verification board prior to the design or marketing. Only two

national health authorities have issued specific guidance for

mHealth apps; the UK National Health Service (NHS) and

the French Haute Autorite de Santé (HAS)

Brush DJ app had evidence-based reference and

previous baseline studies, which all serve to enhance its

credibility.

Brush Up developed by Big Fun Development

is a Tooth Brush Training game and was titled “App of The

Year” by National Academy of medicine and this app

demonstrated to improve kids brushing in a National

Institute of Health funded study.

Few apps like UC Dental, Family dental Care apps

are customizable as it will help the individuals to use

according to their requirements. Magic Timer, Brushy Time,

Parvathy et al: Mobile dental apps and uMARS

JIDAM/Volume: 7/Issue: 1/Pages 1 - 7/January - March2020

Dental Care, Dental Surgery Stimulator were interesting to

use and provide entertainment which add on to the

Engagement criteria of the app. The performance, ease of use

and navigation is perfect for some of the apps like Brush DJ,

My Dental Care, Text 2 floss apps which add on to

Functionality criteria of a good app. The Graphics, layout

and visual appeal were good in My Bright Smile, Dentist

Office which added to Aesthetics part. Teeth Care Tips, Text

2 floss, My Dental Care, UC Dental apps contain high

quality information with references from credible source like

American Dental Association, American Dental Hygienists

Association, The Centres for Disease Control and Prevention,

National Institute of Health, World Health Organization

which will add on to the information criteria of the app

quality. This is contradictory to the study conducted

previously by Singh P in 2013 on orthodontic apps.

Some features like Emergency steps was present in

UC Dental app which can guide the patient in any dental

causalities. Studies conducted by Al Musawi et al in 2017

showed that apps are an effective means of providing

knowledge and guiding lay people in managing tooth

avulsion, and it can be superior to a lecture-based delivery of

information.

Reminders to floss the teeth can be send by

Text 2 floss app which helps to reinforce the flossing habit

in patients. The ADA recommends brushing twice a day and

cleaning between teeth with floss (or another interdental

cleaner) once a day.

Private clinics apps were also available in the app

store which were not included in this study. Apps developed

by the Lin CY et al in 2014 remind patients about every

scheduled appointment, and help them take pictures of their

own oral cavity parts. Dentists could confirm or change

appointments easily and provide professional advice to their

patients immediately taking advantage of cloud-based

services.

There can be a time discrepancy between the

literature search, first submission and publication date and is

ever so relevant in today’s technological era and thus

implies that the reviewed apps (within this study ) may be

updated and newer apps may be available during the time of

peer review process or any delays associated with eventual

publication of this manuscript.

RECOMMENDATIONS

Despite the rapid expansion of mHealth apps, there

are still significant barriers to expanding the role and

efficacy of mHealth apps in improving the health of

consumers due to lack of regulatory supervision, limited

evidence-based literature, and privacy and security concerns.

The biggest challenge that limits the potentials of mHealth

apps is the lack of proper regulation to ensure their accuracy,

quality, and performance. Governmental agencies, third-

party companies, professional societies, and mHealth

researchers must try to come up with standards and

systematic methods like MARS to evaluate and certify Oral

Health apps. The future strategy to be adopted in the dental

health sector as regards using mobile apps may include

improving the quality of dental apps using MARS criteria,

maintaining cloud-based personal oral health record across

health care networks, and increasing app prescription by

health care providers.

CONCLUSION

Considering both objective and subjective quality

scores, only two dental apps in this study scored acceptable

and this situation needs immediate improvement. None of

the apps scored good or excellent. Oral disease affects

billions of people worldwide and mobile phone use is on the

rise, and therefore the market is ripe for well-designed and

effective oral health apps. As patient population becomes

empowered and tech savvy, apps must be informative,

entertaining, aesthetically pleasing, customizable, focusing

the target group and also should be evidence based.

Providing tools like mobile apps for monitoring oral health,

diet and physical activity encourages fitness, lifestyle

modifications and increases well-being. Therefore, it can be

safely assumed that mobile apps play an increasingly

important role in holistic patient care which includes

preventive measures ultimately resulting in substantial

reduction in health care costs.

FINANCIAL SUPPORT AND

SPONSORSHIP:

Nil

CONFLICTS OF INTEREST:

There are no conflicts of interest.

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