|Year : 2014 | Volume
| Issue : 4 | Page : 235-240
Oral health promotion among rural school children through teachers: an interventional study
Byalakere Rudraiah Chandrashekar1, Shankarappa Suma2, Jagadeeswara Rao Sukhabogi3, Bhadravathi Cheluvaiah Manjunath4, Amitabh Kallury5
1 Reader, Department of Public Health Dentistry, People's Dental Academy, Bhanpur, Bhopal, India
2 Senior Lecturer, Department of Orthodontics, People's Dental Academy, Bhanpur, Bhopal, India
3 Assistant Professor, Department of Public Health Dentistry, Government Dental College and Hospital, Hyderabad, India
4 Senior Professor and Head, Department of Public Health Dentistry, Postgraduate Institute of Dental Sciences, PGIMS Campus, Pt. BD Sharma University of Health Sciences, Rohtak, Haryana, India
5 Professor and Head, Department of Orthodontics, People's Dental Academy, Bhanpur, Bhopal, India
|Date of Web Publication||5-Dec-2014|
Byalakere Rudraiah Chandrashekar
Reader, Department of Public Health Dentistry, People's Dental Academy, Bhanpur, Bhopal - 462 037, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The lack of national oral health policy and organized school dental health programs in the country call for affordable, accessible, and sustainable strategies. Objectives: The objective was to compare the oral hygiene, plaque, gingival, and dental caries status among rural children receiving dental health education by qualified dentists and school teachers with and without supply of oral hygiene aids. Materials and Methods: This interventional study was conducted among 15-year-old children selected randomly from four schools in Nalgonda district between September 2009 and February 2010. Schools were divided into four different intervention groups. The intervention groups varied in the form of intervention provider and frequency of intervention one of which being the control group. The oral hygiene, plaque, gingival, and dental caries status was assessed at baseline and 6 months following the intervention. SPSS 16 was used for analysis. Results: The preintervention and postintervention comparison within each group revealed a substantial reduction in mean oral hygiene index-simplified (OHI-S), plaque index (PI), and gingival index (GI) at postintervention compared to baseline in group 4 (1.26, 0.87, and 0.74, respectively) followed by group 3 (0.14, 0.37, and 0.12, respectively). The OHI-S, PI, and GI scores increased in group 1 (0.66, 0.37, and 0.34, respectively) and group 2 (0.25, 0.19, and 0.14, respectively). Mean decayed, missing filled surfaces score between the groups was not statistically significant at baseline and postintervention. Conclusion: The dramatic reductions in the OHI-S, PI, and GI scores in the group supplied with oral hygiene aids call for supplying low cost fluoridated toothpastes along with toothbrushes through the school systems in rural areas.
Keywords: Dental health education, Gingival index, Oral hygiene aids, Oral hygiene status, Plaque index, School dental health programs, School teachers
|How to cite this article:|
Chandrashekar BR, Suma S, Sukhabogi JR, Manjunath BC, Kallury A. Oral health promotion among rural school children through teachers: an interventional study. Indian J Public Health 2014;58:235-40
|How to cite this URL:|
Chandrashekar BR, Suma S, Sukhabogi JR, Manjunath BC, Kallury A. Oral health promotion among rural school children through teachers: an interventional study. Indian J Public Health [serial online] 2014 [cited 2019 Nov 14];58:235-40. Available from: http://www.ijph.in/text.asp?2014/58/4/235/146278
| Introduction|| |
Oral diseases such as dental caries and gingival diseases affect about 80% of the school children worldwide.  The pain and tooth loss associated with oral diseases adversely affect the appearance, nutritional intake, quality-of-life, growth, and development of children. The cost of treating dental caries alone can overwhelm a country's health care expenditure for children and developing countries like India cannot afford treatment of established dental diseases.  The cost of neglect of these diseases is also high due to the personal, financial, and social impacts.  The best possible approach for many developing nations is to focus on prevention of these diseases. The oral diseases are preventable in their early stages, but unfortunately, the knowledge that these diseases can be prevented by simple self-controlled oral hygiene procedures is not known to many of the children, their parents, teachers as well as the policymakers. , The upward trend in most dental diseases ,, in spite of developing the economy, raising dental manpower ,,, in India call for strategic approaches based on the principles of primary health care for the promotion of oral health as well. The lack of national oral health policy and organized school dental health programs in the country prompted us to undertake the present interventional study to compare the oral hygiene, plaque, gingival, and dental caries status among rural children receiving dental health education (DHE) by qualified dentists and school teachers with and without supply of oral hygiene aids.
| Materials and Methods|| |
This was an interventional study conducted over a period of 6 months from September 2009 to February 2010. Though, the groundwork for the study began in May, the actual intervention started from September 2009 and lasted up to February 2010. The ethical clearance for the study was obtained from the Institutional Ethics Committee, Kamineni Institute of Dental Sciences, Narketpally. The study was conducted among 15-year-old children selected from four rural schools in Nalgonda District, Andhra Pradesh, India. Among the 59 mandals (administrative divisions within the district) in the district, one mandal was selected for the study by simple random sampling. A list of all the secondary schools in selected mandal was obtained, and four schools were selected using the table of random numbers. A schedule was prepared in consultation with the headmasters of selected schools for carrying out free dental check-up and treatment camps. Besides, the schools were adopted by the dental institution to offer free dental services to the children on a regular basis using the mobile dental clinic. The screening of all the children in the selected schools for gross oral defects that required immediate treatment was carried out and emergency services were offered either in the mobile dental clinic on the same day or in the dental institution with the referral. During the time of initial screening, DHE was offered to all the children by three dentists and the headmasters of these schools were informed about the study protocol.
The results of a previous study  were used for estimating the sample size. The sample size was computed to be 40 in each group with a statistical power of 70% at 5% level of significance using nMasters 2.0 Sample size software (Department of Biostatistics, Christian Medical College, Vellore). The list of all grade nine students was obtained in each school, and the date of birth as per school records was noted to ascertain the age. The demographic details and the information on oral hygiene practices, diet, oral habits, history of systemic diseases, history on any medications being prescribed on a continuous basis were obtained using a predesigned questionnaire. These children were again screened by a qualified public health dentist for any gross oral defects that interfered with chewing, a severe malocclusion, and dental appliances. A list of children aged 15 years and free from systemic diseases, deleterious and parafunctional oral habits, gross oral defects, a severe malocclusion, and dental appliances was prepared. This was used as a sampling frame for selection of the required number of children in each school. Then, 40 children were selected by using the table of random numbers. The permission to carry out clinical oral examination of the selected children was obtained from their parents through the school authorities, and a verbal consent was taken from each participant at the time of the baseline examination. The children failing to obtain parent's permission or offer verbal consent were replaced by other eligible children in the list.
Each selected participant was given a unique ID. The baseline oral hygiene, plaque, gingival, and dental caries scores were collected from all the 160 students by three trained and calibrated dentists using oral hygiene index-simplified (OHI-S),  plaque index (PI),  gingival index (GI),  and decayed, missing filled surfaces (DMFS) index.  The clinical oral examination was carried out on a plastic chair using a mouth mirror and Number 5 explorer under natural daylight in the school premises. The information was entered on the data collection sheet. The training and calibration of dentists in the application of OHI-S, PI, GI, and DMFS index was carried out on a group of 20 children. Kappa co-efficient for the inter-examiner consistency was found to be 0.86, 0.81, 0.79, and 0.94 for OHI-S, PI, GI, and DMFS index, respectively.
The four schools were then divided into four intervention groups: Group 1 control group with no subsequent DHE after the initial health education offered at the time of screening, group 2- DHE by a qualified dentist at 3 months interval using the audio-visual aids, group 3- DHE by the trained school teachers with screening for gross calculus deposits, debris, etc. on a fortnightly basis, group 4- DHE by the trained school teachers with screening for gross calculus deposits, debris, etc., on a fortnightly basis and these children were also provided the oral hygiene aids (tooth brush and tooth paste). The brochure on oral hygiene practices, the importance of dental health in relation to general health, etc., was prepared in local language by a qualified public health dentist and this was used for educating the children in group 2 as well as for training the teachers. Two active teachers involved in teaching grade nine children in schools allocated to groups 3 and 4 were trained by a qualified public health dentist on oral hygiene practices (method of brushing, importance of rinsing the mouth after each food intake, etc.) along with a practical demonstration for carrying out screening using plastic disposable spoons for gross calculus and debris deposits on a group of children. The emphasis during the training was on demonstrating the teachers on seating the child for screening, operator's position, retraction of cheek using plastic disposable spoons along with explaining how the normal gingiva, diseased gingiva, calculus, and debris deposits appear. The brochure containing color photographs of normal and diseased gingiva, calculus and debris deposits were handed over to the teachers. The training was carried out in one of these two schools for a total of 6 h on 3 different days (2 h sessions on 3 working days). After training, the headmasters of the schools in groups 3 and 4 were requested to allot 1 h time slot every fortnight for these trained teachers to educate the children on oral hygiene practices and to conduct a screening for calculus and debris deposits. The screening was carried out in natural daylight on a plastic chair, and disposable plastic spoons were used for cheek retraction. The trained teachers undertook the task of offering DHE to grade IX children in their schools every fortnight along with screening for debris and calculus deposits. In addition to this, the children in group 4 were given the oral hygiene kits (100 g tooth paste and tooth brush) at 3 months interval.
The postintervention examination was carried out in one of the schools for all the children. To ensure investigator blinding, all the children were instructed to come in color dress on the day of oral examination, assembled in a hall and examined on a random basis by the same investigators who undertook the baseline examination for oral hygiene, plaque, gingival, and dental caries status using OHI-S, PI, GI, and DMFS index, respectively. The recording was made on the data collection sheet, and one of the teachers entered the unique ID of each child, postexamination. The data were entered onto a personal computer, and statistical analysis was done using SPSS 16.0 (SPSS for Windows, Version 16.0. Chicago, SPSS Inc). The mean OHI-S, PI, GI, and DMFS index scores between different groups at baseline and 6 months following the intervention were compared using one-way ANOVA with Tukey's posthoc test. The mean OHI-S, PI, GI, and DMFS index scores between preintervention and postintervention in each group were compared using a paired t-test. The statistical significance was fixed at 0.05. The autoclaved instruments were used for the oral examination of the children.
| Results|| |
The study started with 40 students in each of the four schools (groups). The postintervention examination could not be done among 19 students (from four groups) as they were either consistently absent, dropped out or had changed the school. A total of 141 children from four intervention groups who were available for postintervention examination were only considered for the final analysis [Table 1]. The dropout rate was 11.9%. Majority of these children were from the lower middle or lower classes and only 18-27% of the children reported using brush and paste for cleaning their teeth while others were using finger with mud, charcoal, etc. Almost all the children cleaned their teeth once daily in the morning.
|Table 1: Sex distribution of the study population in different intervention groups (n = 141)|
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Mean oral hygiene index-simplified, plaque index, and gingival index at baseline
The baseline OHI-S among the study population was 4.02 with a standard deviation (SD) of 1.46. The mean PI and GI at baseline in the study population were 2.39 ± 0.23 (mean ± SD) and 1.78 ± 0.52, respectively. There was no statistically significant difference in the mean OHI-S (P = 0.73), PI (P = 0.22) and GI (P = 0.40) between the intervention groups at baseline [Table 2].
|Table 2: Mean OHI-S, PI and GI between baseline and 6 months after the intervention in different groups (n = 141)|
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Mean oral hygiene index-simplified, plaque index, and gingival index, postintervention between the different groups
Oral hygiene index-simplified
The mean OHI-S for the study population 6 months after the intervention was 3.91 ± 1.48. The mean OHI-S was least in group 4 (2.70 ± 1.27) and the highest in group 1 (4.67 ± 1.72). The difference in OHI-S scores between different groups was statistically significant (P < 0.01) [Table 2]. The posthoc test revealed a significant difference between group 1 and others (P < 0.01).
The mean PI 6 months following the intervention was 2.23 ± 0.76 in the study population. The PI was highest in group 1 (2.83 ± 0.41) and least in group 4 (1.50 ± 0.88). The difference in the PI between various groups was statistically significant (P < 0.01) [Table 2]. The posthoc comparison showed a statistically significant difference between group 1 and others (P < 0.01).
The mean GI, postintervention in the study population was 1.69 ± 0.63. The GI was the lowest in group 4 (1.03 ± 0.49), followed by group 3 (1.65 ± 0.79), and the highest in group 1 (2.18 ± 0.47). The difference in the GI between different groups was statistically significant (P < 0.01) [Table 2]. The posthoc test found the difference between group 1 and others to be significant (P < 0.01).
Oral hygiene index-simplified, plaque index and gingival index, between preintervention and postintervention
The difference in the OHI-S score between the baseline and postintervention for the study population as a whole was not statistically significant (P = 0.12) [Table 2] though there was a marginal decrease postintervention. The OHI-S score significantly increased postintervention compared to baseline in groups 1 and 2 (P < 0.01) [Table 2]. The OHI-S score decreased in groups 3 and 4 postintervention compared to the baseline. The decrease was not statistically significant in group 3 (P = 0.07) [Table 2] but was significant in group 4 (P < 0.01) [Table 2]. The PI score significantly decreased postintervention compared to baseline in the study population (P < 0.001) [Table 2]. The plaque score significantly increased in groups 1 and 2 (P < 0.01) [Table 2] postintervention but decreased in groups 3 and 4 (P < 0.01) [Table 2]. The GI decreased significantly, postintervention compared to the baseline in the study population (P = 0.03) [Table 2]. The score significantly increased in groups 1 and 2 (P < 0.01) [Table 2] but decreased in group 3 (P = 0.02) [Table 2] and group 4 (P < 0.01) [Table 2]. The results clearly revealed a substantial reduction in OHI-S, PI, and GI postintervention in group 4 (1.26, 0.87, and 0.74, respectively) followed by group 3 (0.14, 0.37, and 0.12, respectively). The mean OHI-S, PI, and GI scores increased in group 1 (0.66, 0.37, and 0.34, respectively) and group 2 (0.25, 0.19, and 0.14, respectively).
Decayed, missing filled surfaces
The study found no significant difference in the mean DMFS scores at baseline (P = 0.65) [Table 3] as well as postintervention (P = 0.56) [Table 3] between the groups. There was also no significant difference between baseline and postintervention DMFS scores in each group.
|Table 3: Mean DMFS at baseline and 6 months following the intervention in different groups (n = 141)|
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| Discussion|| |
It is a common practice in India that the DHE is infrequently offered by the dental professionals. The DHE is offered to school children as part of the dental checkup and treatment camps that are organized sporadically. In the present study, we assessed and compared the effectiveness of DHE offered on an infrequent basis by dental professionals with that offered by school teachers at frequent intervals. This was the rationale for deliberately keeping the DHE frequency at 6 and 3 month's interval for dental professionals while every fortnight for trained teachers. This provided an opportunity to compare the effectiveness of routinely followed method of DHE by dental professionals with an innovative concept that utilizes the services of school teachers in their regular school curriculum.
The increase in the mean OHI-S, PI, and GI scores postintervention compared to baseline in groups 1 and 2 suggest that the infrequent DHE by dental professionals, a common practice by majority of the dental institutions in the country, has not contributed significantly in the promotion of oral hygiene and gingival health among rural school children. The reduction in these scores, postintervention compared to baseline in groups 3 and 4 reflect that the frequent DHE by trained teachers along with screening for gross deposits of debris and calculus will help in the promotion of oral hygiene and gingival health. The fact that the children wish to get appreciation by their teachers whom they respect and regard might have prompted them to improve their oral hygiene practices in groups 3 and 4, which in turn might have improved their gingival health as well. In our earlier study,  on the use of school teachers in the promotion of oral hygiene among secondary students in urban areas, we found that the frequent DHE by trained teachers was more effective than the infrequent DHE by qualified dentists. The screening by the teachers for debris and calculus deposits, along with continuous reinforcement on the importance of oral hygiene on a fortnightly basis might have indirectly influenced the children to perform better in their oral hygiene practices in an effort to be praised by their teachers. The results of this study were consistent with the findings of this study and others. ,, The lack of significant difference in dental caries between different groups is attributed to the fact that dental caries is a chronic disease involving the calcified structures of teeth. The short duration of the study would not have been sufficient to bring a noticeable change in dental caries. However, the benefits accrued in terms of improved oral hygiene may show their benefit in caries prevention in the long run which could not be elicited in the present study.
Another study in India  found that the frequent DHE sessions resulted in a significant improvement in oral health knowledge, practices and reductions in the PI scores. They found that the schools with frequent exposure to DHE programs scored better in all aspects compared to schools with less frequent exposures similar to the findings of our study.
The fact that the cost may become a barrier for the children from low-income families, in spite of personal motivation and supervision by teachers is highlighted by the differences in the OHI-S, PI and GI scores noted between groups 3 and 4. The supply of oral hygiene aids free of cost along with motivation and personal supervision by teachers might have made the children in group 4 more enthusiastic in maintaining the oral hygiene practices that has improved their gingival health. This finding call for supplying low cost fluoridated toothpastes along with toothbrushes through the school systems especially in rural areas where most of the children come from families which cannot afford to buy the toothbrush and tooth paste. The developing countries like India which does not have national oral health policy, organized school dental health programs, and lack of budget to utilize the services of trained dental manpower can definitely consider training the teachers on short-term basis. The utilization of the services of trained school teachers for the promotion of oral hygiene among the school children will become a part of the regular curriculum without disturbing the routine school schedule.
| Conclusion|| |
The results of this study showed that the concept of utilizing the teachers for the promotion of oral hygiene among secondary students is definitely feasible. The frequent DHE by trained teachers was found to be more effective than infrequent DHE by qualified dentists. The study found that the teachers can undertake the task of screening children for gross deposits of debris and calculus on a periodic basis with short-term training. The more dramatic reductions in scores in the group 4 call for supplying low cost fluoridated toothpastes along with toothbrushes through the school systems especially in rural areas. These results reflect only short-term changes in oral hygiene among secondary school students. Further, long-term studies with more number of schools are required to validate the results of this study. However, the study highlighted that the utilization of teachers may be explored for oral health promotion among school children in India and other developing countries.
| Acknowledgments|| |
I would like to bestow my respected thanks with gratitude to the Principal and management of Kamineni Institute of Dental Sciences and Research Center for their continuous support and encouragement throughout this project. My sincere thanks to the District Education Officer, Nalgonda, the Headmasters of the schools concerned, and the participants for their co-operation. With the deepest sense of admiration and gratitude, I express my thanks to interns who assisted in this project.
| References|| |
Petersen PE. The World Oral Health Report 2003: Continuous improvement of oral health in the 21 st
century - The approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23.
Yee R, Sheiham A. The burden of restorative dental treatment for children in Third World countries. Int Dent J 2002;52:1-9.
Mouradian WE, Wehr E, Crall JJ. Disparities in children's oral health and access to dental care. JAMA 2000;284:2625-31.
Petersen PE, Danila I, Samoila A. Oral health behavior, knowledge, and attitudes of children, mothers, and schoolteachers in Romania in 1993. Acta Odontol Scand 1995;53:363-8.
Al-Tamimi S, Petersen PE. Oral health situation of schoolchildren, mothers and schoolteachers in Saudi Arabia. Int Dent J 1998;48:180-6.
Patro BK, Ravi Kumar B, Goswami A, Mathur VP, Nongkynrih B. Prevalence of dental caries among adults and elderly in an urban resettlement colony of New Delhi. Indian J Dent Res 2008;19:95-8.
Dhar V, Jain A, Van Dyke TE, Kohli A. Prevalence of gingival diseases, malocclusion and fluorosis in school-going children of rural areas in Udaipur district. J Indian Soc Pedod Prev Dent 2007;25:103-5.
Dhar V, Bhatnagar M. Dental caries and treatment needs of children (6-10 years) in rural Udaipur, Rajasthan. Indian J Dent Res 2009;20:256-60.
Nash DA, Friedman JW, Kardos TB, Kardos RL, Schwarz E, Satur J, et al
. Dental therapists: A global perspective. Int Dent J 2008;58:61-70.
Ahuja NK, Parmar R. Demographics & current scenario with respect to dentists, dental institutions & dental practices in India. Indian J Dent Sci 2011;3:8-11.
Mahal AS, Shah N. Implications of the growth of dental education in India. J Dent Educ 2006;70:884-91.
Rajkumar K, Malini VV. Reviving the scope of dentistry in India. SRM Journal of Research in Dental Sciences 2010;1: 203-4.
Chandrashekar BR, Suma S, Kiran K, Manjunath BC. The use of school teachers to promote oral hygiene in some secondary school students at Hyderabad, Andhra Pradesh, India: A short term prospective pilot study. J Family Community Med 2012;19:184-9.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.
Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38 Suppl:610-6.
Klein H, Palmer CE, Knutson JW. Studies on dental caries, dental status and dental needs of elementary school children. Public Health Rep 1938;53:751-65.
Gift HC, Reisine ST, Larach DC. The social impact of dental problems and visits. Am J Public Health 1992;82:1663-8.
Goel P, Sehgal M, Mittal R. Evaluating the effectiveness of school-based dental health education program among children of different socioeconomic groups. J Indian Soc Pedod Prev Dent 2005;23:131-3.
Redmond CA, Blinkhorn FA, Kay EJ, Davies RM, Worthington HV, Blinkhorn AS. A cluster randomized controlled trial testing the effectiveness of a school-based dental health education program for adolescents. J Public Health Dent 1999;59:12-7.
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;21:253-9.
[Table 1], [Table 2], [Table 3]