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Development of a new technique (ATP) for training visually impaired children in oral hygiene maintenance.


Major improvements in oral health have occurred in many developed countries over the last 30 years. However oral diseases are still prevalent in developing countries and their impact on both society and the individual are significant. The costs of treatment are high, although the causes of the diseases are known and largely preventable [Watt and Fuller, 2007].

Regular removal of dento-gingival plaque is crucial for the maintenance of periodontal health. Mechanical cleaning is recognised to be potentially useful in controlling supragingival plaque, but the expectation that each individual will maintain a good standard seems to be beyond most people's capabilities. A number of factors have been suggested as playing a role in motivation of patients for performing oral hygiene procedures. Most important amongst these factors are a patient's recognition of disease and the knowledge of various preventive measures [Albandar and Rams, 2002].

The situation becomes more complex when dealing with physically or mentally challenged people. The visually impaired have oral health problems similar to those seen in the general population. It is necessary to emphasise the importance of oral care for these individuals. They should be guided in the elimination and/or reduction of dental biofilm and health promotion. Knowledge should also be imparted regarding functionality and the conservation of dental elements and aesthetics, although aesthetics might not have a high priority for them. Motivating individuals with visual impairments to have good oral hygiene is a major challenge for dental surgeons, because the typical techniques used to show the dental biofilm may not be effectively used [Deborah et al., 2005]. Techniques should be custom designed according to patients' needs, incorporating the basic principles. Studies regarding oral health education of visually impaired are very sparse. Hence the present study was planned, the objective of which was to describe one such technique that was developed to educate visually impaired children regarding tooth brushing. The second objective was to assess and compare plaque scores before and after health education.

Materials and methods

Socio-demographic Information This was a part of a longitudinal study which was conducted among children of 'Maheshwari School for the Blind' of Belgaum city. Belgaum city is district headquarters, located in South India. Maheshwari School is the only residential school which caters for visually impaired children of Belgaum district. This research was approved by the institutional ethics board. The study was conducted during the period of December 2008 to July 2010 after obtaining permission from school authorities.

There were a total of 120 visually impaired children aged 6-18 years old in the school. Ten of them were too young to understand the brushing technique and were not included in the study. At follow-up 14 subjects had completed their education and left the school. Hence only 96 subjects remained in the study.

As most of the children were staying in the hostel in the school premises verbal consent from the parents were taken by telephone at the start of the study and later when the children went home for a vacation once written informed consent was obtained from parents. It was a non-randomised before and after comparison trial without controls. The baseline value of the same group served as its own control.

Study Protocol The study was conducted at various stages--

Stage--1 (Interaction): A series of interactive sessions were conducted with the visually impaired children to understand their level of co-operation and comprehension.

Stage--2 (Pre-Education Examination): A self designed format was used to record personal details of the child such as name, age, gender, reasons for blindness and method of tooth brushing. This was followed by recording of Silness and Loe plaque index [Silness and Loe, 1964]. Prior training was given to two examiners for recording data and conducting examinations. Indices were recorded on 10 children in the department of Public Health Dentistry. The inter-examiner reliability was found to be 0.78. Based on the scores the children were categorised as Excellent (0), Good (0.1 to 0.9), Fair (1.0 to 1.9) or Poor (2.0 to 3.0).

Stage--3 (Health Education): A series of interactive sessions were conducted at the beginning of the study and it was found that they had good knowledge about oral health but lacked appropriate oral hygiene performance. Hence it was decided that they required a special health education method by which they could easily master the correct brushing technique. 'Audio tactile performance technique' (ATP), a specially designed health education method, was used to educate these children regarding oral hygiene maintenance. A total of four health educators were trained regarding the method of health education in the Department of Public Health Dentistry before educating the children. The method was so named as children were first verbally informed about the importance of teeth, method of brushing and then they were made to feel the teeth on a large sized model followed by brushing on the model using the Fones method with assistance. This was repeated until the children could perform with ease.

The children were asked to feel their own teeth with their tongue and any deposits to be appreciated by feeling of roughness. Then they were asked to brush their own teeth with the assistance of one of the trained educators. They were also taught regarding the amount of tooth paste to be used. There was no time restriction for health education, and the process continued for each child individually until they could perform it independently, correctly and confidently.


Periodic reinforcement using the same methods was performed at an interval of 9 months. The children were asked to recollect what they could remember from the first health education session. Based on that approach, reinforcement was performed for all the students.

Stage--4 (Post-Education Examination): Oral examination was conducted 18 months after imparting health education to assess plaque scores. Examination was performed by the same examiners.

Data Analysis Data obtained was entered into Excel sheet and analysed using SPSS version 17 (Chicago IL USA). Wilcoxon's sign rank test and paired t test was used to assess the difference between the scores before and after health education.


Distribution of study subjects is shown in Figure 1. Out of 96 subjects 65 were males and 31 were females. Of these 67 were partially blind and 29 were completely blind.

Table 1 shows distribution of the study population according to method and frequency of tooth brushing. 84 subjects used tooth brush and tooth paste to clean their teeth at baseline. A slight increase in number was observed post-health education which was not statistically significant (p = 0.34). There were 56 subjects who brushed twice daily after health education compared to only 44 subjects before health education. The difference was not statistically significant (p = 0.08).

The distribution of subjects according to plaque scores is shown in Table 2. There were 30, 50 and 15 subjects respectively in good, fair and poor categories at baseline. After health education 77, 16 and 1 subjects respectively were categorized as in good, fair or poor. The difference was statistically significant (p < 0.001).

Mean plaque scores are shown in Table 3. Mean plaque scores pre- and post-health education were 1.41([+ or -]0.58) and 0.63([+ or -]0.39) respectively. The difference was statistically significant (p < .001).


Health education, a widely accepted approach in prevention of oral diseases, is a process of transmission of knowledge and skills necessary for improvement in quality of life. The goal of planned health education programs is not only to bring about new behaviours but also to reinforce and maintain healthy behaviours that will promote and improve individual, group or community health.

Schools are thought to be the most suitable environment to provide health information to children in order to achieve the goal of health education program. As schoolchildren are relatively accessible and already in a learning environment, dental health education in such settings are most effective [Zickert et al., 1982; Albandar et al., 1994; Morishita et al., 2003].

The assumption that oral health education may modify children's oral health knowledge and consequently change children's oral health behaviour is controversial. Yet health education as a tool of prevention should not be neglected. Children must be taught not only the causes of oral diseases but also the current preventive measures to avoid them. School education programs will enable children to make decisions about oral health regarding their own children in the future or even their community [Ercalik and Atalay, 2006].

People with visual impairments deserve the same opportunities for oral health and hygiene as those who are healthy. Unfortunately, oral health care is one of the greatest unattended health needs of visually impaired people. Various studies have shown that they do express concerns about the oral cavity, particularly its functional aspect. This indicates that even though they cannot see, they understand the functional importance of the teeth and mouth. The aesthetic aspect of oral hygiene is infrequently mentioned and seems to have less relevance to these individuals. Pain is the main factor for seeking dental care [Maciel et al., 2009]. Health education regarding maintenance of oral hygiene is more important among visually impaired children to reduce the additional burden of oral diseases. Hence this study was planned to design a customised brushing technique to improve oral health.

Most of the children used tooth brush and tooth paste to clean their teeth at base line. However the frequency was only once daily. It is a common custom in India to clean teeth daily in the morning, hence most of the children brushed once daily. After health education the frequency increased to twice daily among most of the subjects. There was a significant reduction in the plaque scores after health education. Most of the subjects changed from poor and fair categories to the good category post-health education which was statistically significant (p<0.001). This shows that merely using tooth brush and paste will not help to improve the oral hygiene. The correct brushing technique and frequency is more important.

It has been reported that the absence of visual stimuli prevents rapid learning, representing a challenge for dentists in motivating these individuals to have appropriate oral hygiene. This is in contrast to the present study where they could learn satisfactory brushing techniques when well trained, thus maintaining healthy oral conditions. This could be due to the fact that these children were staying in a residential school and lead a disciplined life style and were very receptive to learning new things. The efficiency of education and motivation for oral hygiene in these patients was confirmed in studies reported by Maciel and co-workers [2009] and that a marked reduction in rates of dental biofilm occurs, mainly due to the assimilation of techniques appropriate to achieving oral hygiene and therefore the acquisition of healthy habits and routines which is in accordance with the present study.

The health education method in this study was very successful resulting in reduction in plaque scores. The strong motivation of children and meticulous training and reinforcement by the health educators could have led to success. Only one study has shown a similar detailed health education process among three visually impaired children with improvement in oral health [Shih and Chang, 2005]. One should develop individual health education technique according to the needs of the subjects.

Assessment of knowledge, attitude and practice before and after intervention was not performed in the present study. However this is a meticulous task and requires involvement of trained personnel in preparation of questionnaires using Braille scripts.

Reducing the oral disease burden among visually disabled people may be have long-term benefits. Lack of time, knowledge and experience, and a constrained work environment (including restricted financial resources) may act as a hindrance for dentists to serve this group of subjects. Cost, fear, and negative attitudes to dentistry may prevent the subjects from availing the appropriate dental treatment [Bedi et al., 2001; Edwards et al., 2002; Hallberg et al., 2004].


People with disabilities deserve the same opportunities for oral health and hygiene as those who are healthy. The present study showed that visually impaired children can maintain an acceptable level of oral hygiene when taught with special customised methods.


The authors express their gratitude to all the participants of the study. The authors would also like to acknowledge all the staff members and postgraduate students of the Departments of Public Health Dentistry, Pedodontics and Preventive Dentistry and of Periodontics, KLE VK IDS for assisting in the treatment of the study subjects.


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M. Hebbal, A.V. Ankola

Department Of Public Health Dentistry, KLE VK Institute of Dental Sciences, KLE University, Belgaum, India.

Postal address: Dr M. Hebbal, Department Of Public Health Dentistry, KLE VK Institute of Dental Sciences Belgaum, India.

Table 1. Distribution of children according to oral
hygiene practice.

                   Pre-health   Post-health   McNemar's
                   education     education    Chi square
                   frequency     frequency     p value

Tooth Brush and        84           88         p = 0.34
  Tooth Paste
Finger and Tooth       12            8


Twice Daily            44           56         p = 0.08
Once Daily             52           40

Table 2. Distribution of children according to plaque

            Pre-health   Post-health    Wilcoxon
            education     education    signed-rank
            frequency     frequency       test
                                         p value

Excellent       1             2           -7.36
Good            30           77         p < 0.001
Fair            50           16
Poor            15            1
Total           96           96

Table 3. Comparison of pre- and post- mean plaque scores in a
group of visually impaired Indian children.

                          Mean             Mean           Mean
                       pre-plaque      post-plaque     difference

Pre-plaque--              1.41             0.63           0.78
post-plaque scores   ([+ or -]0.58)   ([+ or -]0.39)

                     Std. Deviation   t value   Sig. (2-tailed)

Pre-plaque--              0.4         17.517        < 0.001
post-plaque scores
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Article Details
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Author:Hebbal, M.; Ankola, A.V.
Publication:European Archives of Paediatric Dentistry
Article Type:Report
Geographic Code:9INDI
Date:Oct 1, 2012
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