Year : 2010 | Volume
: 21 | Issue : 2 | Page : 253--259
Effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12- to 13-year-old school children
Rekha P Shenoy1, Peter S Sequeira2,
1 Department of Community Dentistry, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore - 575 018, India
2 Coorg Institute of Dental Sciences, Virajpet, India
Rekha P Shenoy
Department of Community Dentistry, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore - 575 018
Background: Children with poor oral health are 12 times more likely to have restricted-activity days. Dental health education [DHE], with the objective of improving the oral hygiene of the participants, would have obvious merits.
Objectives: To determine the effectiveness of school DHE, conducted at repeated and differing intervals, in improving oral health knowledge, practices, oral hygiene status, and the gingival health of schoolchildren belonging to two socioeconomic classes.
Materials and Methods: This 36-week duration study assessed the effectiveness of school DHE conducted every three weeks against every six weeks on oral health knowledge, practices, oral hygiene status and gingival health of 415, 12- to 13-year-old schoolchildren belonging to social classes I and V. Of the three selected schools of each social class, one each was subjected to the intervention of either three or six weeks or was a control, respectively. Oral health knowledge and practices were evaluated using a questionnaire. Oral hygiene and gingival health were assessed using plaque and gingival indices.
Statistical Analysis Used: Friedman«SQ»s test was used for the longitudinal analysis of data. ANOVA and Student«SQ»s t test were used for continuous data.
Results: Plaque and Gingival score reductions were highly significant in intervention schools, and were not influenced by the socioeconomic status. When oral health knowledge was evaluated, highly significant changes were seen in intervention schools; more significantly in schools receiving more frequent interventions. The socioeconomic status influenced the oral hygiene aids used and the frequency of change of toothbrush. Controls showed no significant changes throughout.
Conclusions: The DHE program conducted at three-week intervals was more effective than that conducted at six-week intervals in improving oral health knowledge, practices, oral hygiene status, and gingival health of schoolchildren.
|How to cite this article:|
Shenoy RP, Sequeira PS. Effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12- to 13-year-old school children.Indian J Dent Res 2010;21:253-259
|How to cite this URL:|
Shenoy RP, Sequeira PS. Effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12- to 13-year-old school children. Indian J Dent Res [serial online] 2010 [cited 2021 May 14 ];21:253-259
Available from: https://www.ijdr.in/text.asp?2010/21/2/253/66652
Children who suffer from poor oral health are 12 times more likely to have more restricted-activity days, including missing school, than those who do not. Annually, more than 50 million hours are lost from school due to oral diseases. 
Few aspects of health are as accessible to personal control as oral hygiene, which can be improved by simple behavioral changes.  A dental health education [DHE] program, which has as its objective, the improvement of the oral hygiene status of the participants would have obvious merits.  DHE encompasses publicity campaigns, occasional talks at an elementary school, a showing of dental health films, and an extensive, reinforced program in a school curriculum. , Several factors are important for effective DHE such as repetition and reinforcement of oral hygiene instructions. These concepts show significant, positive, short-range and long-term effects. 
Adolescents are in particular need of preventive programs as they have high levels of plaque and their oral hygiene practices are based on short-term rewards [to improve appearance and social attractiveness]. 
Therefore, this study was conducted with the following objectives:
To determine whether DHE given at three-week intervals for 18 weeks was more effective than DHE given at six-week intervals for 18 weeks in improving oral health knowledge, practices, oral hygiene status, and gingival health in 12- to 13-year-old schoolchildren.To determine if there was retention of oral health knowledge and improved practices, 18 weeks after cessation of the program, in subjects who received DHE at three-week intervals for 18 weeks.To determine if the socioeconomic status played a role in influencing oral health knowledge, practices, oral hygiene status, and gingival health of schoolchildren.
Materials and Methods
A study of 36-week duration was conducted in Mangalore City to assess and compare the effectiveness of school DHE, conducted at varying time intervals (every three weeks as against every six weeks). Located in Karnataka State on the south-western coast of the Indian peninsula, with a population of approximately 600000, Mangalore is a reputed center of educational, cultural, financial, and healthcare activities.
The socioeconomic status evaluation was based on the revised Kuppuswamy Socioeconomic Status Scale, 2003,  which divides subjects into five classes based on education, occupation, and income. The socioeconomic status of the subject's parents was evaluated and children of socioeconomic classes I and V were selected as the study subjects. The sample size was 400 [according to the Altman's nomogram,  taking power of the test as 0.85 and standardized difference as 0.30].
The study design required six schools. Details of schools and permission to carry out the study were obtained from the Block Education Officer (BEO). School selection was based on the following criteria: (1) consent of the school authorities (2) no DHE programs conducted in the past or during the study period (3) children belonging to either social class I or V (4) at least 50 children in the age group of 12 to 13 years. Eleven schools fulfilled the above criteria, of which three, each with children from social classes I and V, were selected by convenience sampling.
Within each school, the study subjects were selected based on - inclusion criteria: (a) male and female children of age 12 to 13 years, (b) intact permanent teeth, and (c) good general health; exclusion criteria: (a) presence of oral mucosal lesions, (b) intake of medications affecting oral health [antibiotics, mouthwashes] in the two weeks leading to the study and before each examination, (c) presence of crowding/overlapping of teeth resulting in severe gingival inflammation, (d) children undergoing orthodontic treatment, and (e) children requiring any emergency dental treatment. Children numbering 231 and 219 from social classes I and V, respectively, fulfilled the above criteria and were included in the study. Children requiring emergency dental treatment were referred to the nearest center for appropriate care.
The three schools in each social class were numbered as follows: Social class I - schools 1A, 1B, 1C; social class V - schools 2A, 2B, 2C. The study design is given in [Figure 1]. After baseline assessment of plaque levels, gingival status, oral health knowledge, and practices, the schools were allotted to active and control groups. In the next 18 weeks, subjects in the active group received DHE at three-week intervals. Two schools from each social class were taken as controls, to prevent 'contamination' of the program within schools due to the children talking to each other (because of the change, at 18 weeks, to active status of one of the two control schools in each social class). At 18 weeks, the subjects were evaluated for plaque levels, gingival status, oral health knowledge, and practices. Then, the control group (schools 1B and 1C and 2B and 2C) was split into a new active group (schools 1B and 2B) and residual control group (schools 1C and 2C). In the next 18 weeks, the new active group received DHE at six-week intervals, while the program was withdrawn from the original active group. At 36 weeks, the subjects were revaluated. After completion of the study, DHE sessions were conducted for children of schools 1C and 2C, for ethical reasons.
A 24-item questionnaire assessed oral health knowledge and reported practices in all three phases of the study. Its precision and validity were assessed through a pilot study carried out on subjects, similar to the study population. Questionnaires were completed in class under the supervision of the class teacher.
Plaque levels and gingival status of the subjects were assessed using the Plaque Index (Silness and Lφe, 1964)  and the Gingival Index (Lφe and Silness, 1963).  Investigator training and calibration were carried out at baseline, 18 and 36 weeks. The kappa statistic for intra-examiner reliability was found to range from 0.80-0.84.
Assisted by a recording clerk, a single investigator examined the subjects in school corridors or classrooms under adequate natural light. Repeated examinations were performed on five randomly selected children on each examination day to confirm intra-examiner reliability.
Dental health education
Each interactive 20-minute session utilized audio-visual aids (slide projector, dentoform model, charts, photo albums, posters, and plaster models) and focused on: Structure and functions of teeth; types of dentitions and their significance; number and types of teeth present in each dentition; dietary components and their effects on oral tissues; importance of a balanced diet; etiology, clinical manifestations, treatment modalities, and prevention of dental caries; periodontal disease, oral cancer and malocclusion; fluorides; injurious oral habits; effects of orofacial trauma; influence of oral health on general health; importance of brushing teeth twice daily, and mouth rinsing; proper tooth-brushing technique; (modified Bass technique was demonstrated on a dentoform model and reinforced at each subsequent visit); and importance of a regular dental visit.
Data obtained from questionnaires and clinical examinations were subjected to the SPSS Version 14.0. Differences in proportions were compared using the Chi square test and the Fisher's Exact Test. The Friedman's test was used for the longitudinal analysis of the obtained data. For continuous data, ANOVA and Student's t test were used for analysis. A difference was considered to be of statistical significance if the P value was <0.05.
A total of 415 children completed the study. Data obtained from them was subjected to statistical analysis [Table 1].
Changes in the Plaque and Gingival Index scores of the subjects are shown in [Table 2]. Socioeconomic status did not show any influence on the Plaque or Gingival Index scores.
Knowledge on aspects of oral health
Questions were focused on: Functions of teeth, influence of oral health on general health, importance of good oral hygiene, types and number of teeth in each dentition, diet (including sugars) and its effects on oral tissues, etiology and clinical manifestations of dental caries and periodontal disease, ideal daily tooth brushing duration and frequency, ideal time to change a tooth brush, and importance of mouth rinsing after every meal and fluoride.
Evaluation of the questionnaires from baseline to 36 weeks for the above-mentioned parameters showed highly significant increases in the percentage of correct responses in the intervention schools (1A and 2A, 1B and 2B) (P=0.000); changes in schools 1A and 2A being more significant.
Significant differences in responses were present between schools 1A (at 18 weeks) and 1B (at 36 weeks) for questions on importance of teeth, etiology of dental caries, clinical manifestations of periodontal disease (P<0.05); and between schools 2A (at 18 weeks) and 2B (at 36 weeks) for questions on the number of teeth in each dentition, plaque, and ideal daily tooth brushing duration (P>0.05). For the question on when the toothbrush should be changed, there were significant differences between schools 1A and 2A at the end of 18 and 36 weeks, and schools 1B and 2B at the end of 36 weeks (which may be due to differences in the socioeconomic status). Oral health knowledge and practice scores matched in the intervention schools for 'duration of tooth brushing' and 'how often a toothbrush should be changed'.
Oral hygiene practices
Questions on oral hygiene practices gathered information on the following topics.
Oral hygiene aids used
Baseline to 36-week evaluation showed significant increases in the number of children using toothbrush and toothpaste in schools 1B, 2A, and 2B (P<0.05) [Table 3].
Frequency of tooth brushing
Baseline to 36-week evaluation revealed highly significant increases in the number of children brushing twice daily in schools 1A, 1B, 2A, and 2B (P=0.000), the increases in schools 1A and 2A being more significant [Table 4].
Duration of tooth brushing
At baseline, 42% of the children in schools 1A, 1B, and 1C and 37% of the children in schools 2A, 2B, and 2C brushed their teeth for two to three minutes.
Baseline to 36-week evaluation showed highly significant increases in the number of children who brushed their teeth for two to three minutes in schools 1A, 1B, 2A, and 2B (P=0.000), the increases in schools 1A and 2A being more significant. Also, highly significant differences (P=0.019) were seen between schools 1A (at 18 weeks) and 1B (at 36 weeks).
Frequency in change of toothbrush
Baseline to 36-week evaluation revealed significant increases in the number of children who changed their toothbrushes every three months in schools 1A, 1B, 2A and 2B (P < 0.05) [Table 5].
Mouth rinsing after every meal
At baseline, 25% of the children in schools 1A, 1B, and 1C and 23% of the children in schools 2A, 2B, and 2C stated that they rinsed their mouths after every meal.
When baseline to 36-week evaluation was completed, a highly significant increase was seen in the number of children reporting mouth rinsing after every meal in schools 1A, 1B, 2A, and 2B (P=0.000), the increases in schools 1A and 2A being more significant. Also, highly significant differences were seen between schools 1A (at 18 weeks) and 1B (at 36 weeks) (P=0.008), and between schools 2A (at 18 weeks) and 2B (at 36 weeks) (P=0.001).
Bleeding from gums
At baseline, 20% of the children in schools 1A, 1B, and 1C and 12% of the children in schools 2A, 2B, and 2C reported bleeding from gums while brushing.
Baseline to 36-week evaluation showed a highly significant increase in the number of children reporting bleeding from gums in schools 1A, 1B, 2A, and 2B (P=0.000), the increase in schools 1A and 2A being more significant. Also, highly significant differences (P=0.007) were seen between schools 1A (at 18 weeks) and 1B (at 36 weeks).
Responses obtained seemed to indicate that the socioeconomic status influenced the oral hygiene aids used and the frequency in change of toothbrush (most likely due to the fact that subjects depended on caregivers for their procurement). Residual control group (schools 1C and 2C) showed no significant changes in plaque, gingival, oral health knowledge or practice scores throughout the study.
The study design prevented 'contamination' and ensured that the responses obtained were due to the intervention, ,, in contrast to studies with the test and control groups from the same school, where the carry-over effect could not be disregarded. ,,
The lecture-demonstration method of DHE used was similar to the other studies. , Bass method of tooth brushing was taught as it is the easiest and most effective technique for children to learn.  The initially low twice-daily tooth brushing frequency , increased significantly in the intervention schools , in contrast to another study. 
At baseline, approximately 19% of the study subjects knew that bleeding from the gums was symptomatic of gum disease. This increased markedly to almost 100% for the intervention schools at the end of the study.  No significant differences were noted between the social classes. Intervention schools showed significant reductions in plaque and gingival scores as compared to the controls at the end of 36 weeks. ,,,
At baseline, 31% of the subjects knew that sticky/sugary foods caused dental caries. Correct responses increased significantly at the end of the study.  There were significant differences between schools 1A and 1B (Oral health knowledge scores of 1A were better), but not between the two social classes. When asked about the best time to eat sugary foods, only a few correct responses ('at meal times') were obtained at baseline. These increased significantly in all the intervention schools at the end of the study, , in contrast to another study.  There were no differences between the social classes or between schools receiving differing interventions .
Reinforcement through repeated DHE sessions in the intervention schools resulted in significant improvements in oral health knowledge and practices, and reductions in plaque and gingival scores. There was retention of oral health knowledge and maintenance of reduced plaque and gingival scores even after cessation of the program, as seen in schools 1A and 2A at the end of 36 weeks. ,,,,,, On almost all aspects evaluated, schools with more frequent exposures to the program [1A and 2A] scored better than schools with fewer exposures [1B and 2B], ,,,, in contrast to studies of short duration with no reinforcement,  which showed good immediate results but failed to show long-term positive results.
In comparison to social class V, social class I scored better on questions about: 'Importance of teeth,' 'oral hygiene aids used,' 'frequency in change of toothbrush' and 'ideal time to change a tooth brush.' This may be due to the differences in socioeconomic status and the lesser importance that lower socioeconomic classes attach to their teeth. , No significant differences were found between the two social classes on general topics like, 'why we need teeth in our mouth', 'number of deciduous and permanent teeth' and 'diet and its effects on oral tissues.'
Limitations of this study are: (a) schools were not randomly allocated to intervention and control groups; (b) long-term value of the improvements seen need to be confirmed by further studies because improved oral hygiene in children may exist only during the program or for a short period thereafter; (c) DHE was given only once in the residual control group, withholding the benefits of reinforcement; (d) school personnel and teachers were not involved - they might have ensured enduring benefits after discontinuation of program; (e) intervention groups may have derived information from other sources - a difficulty of carrying out research in real-life settings; (f) intervention was targeted only at schoolchildren - not a complete health promotion scenario, as no changes in environment or lifestyle were advocated; (g) an inherent bias was that one of the outcome variables (practices) was measured as self-reported - an over-report of favorable behaviors might be expected; (h) children of other socioeconomic classes were not considered; (i) interference with school curriculum might be an added problem; (j) clinical significance of the changes observed needed to be estimated and interpreted in terms of the overall cost of the intervention (with respect to monetary resources, manpower, and time).
Results of this study can be generalized to situations in India and parts of Southeast Asia, which share similar socioeconomic profiles and cultural traditions, with regard to the importance of oral hygiene.
This study showed that
DHE programs conducted at three-week intervals were more effective than those conducted at six-week intervals in improving oral health knowledge, reported oral hygiene practices, oral hygiene status, and gingival health of 12- to 13-year-old schoolchildren.Oral health knowledge and practice scores at the end of 18 weeks in subjects who received the interventions at three-week intervals were maintained at 36 weeks even though the program was stopped at 18 weeks.Reinforced DHE may improve oral hygiene and gingival health to a significant extent, but may prove inadequate in the long run if low-cost oral hygiene aids are not made available to the general population. Continuance of this program will have a minimal financial effect on the families of subjects belonging to social class I; however, family finances of social class V subjects may be adversely affected.
The authors hope that this study will lead to a ripple effect (in that, oral health knowledge imparted to subjects will be passed on to their peers and family members) and impress on the planners,
The futility of the once yearly DHE programs presently conducted in Indian schools, andThe necessity of (a) providing basic oral hygiene aids free of cost or at concessional rates to the underprivileged; (b) incorporating dental health into the school curriculum; and (c) co-ordinating efforts between school personnel, health professionals, and parents to ensure long-term benefits.
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