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A practical, behavior-based oral hygiene program for elementary school children
At a small school near Lincoln, Neb, a program of oral hygiene was developed that was found to be effective, easily managed, acceptable to parents, and economically feasible.
A practical, behavior-based oral hygiene program for elementary school children
K e n n e th D. K e ith , F ra n k M . W e n tz, R o b e rt M . W oo d,
PhD, Omaha
DDS, PhD DDS, Lincoln, Neb
A three-year study was made of the effectiveness of a behavior-based program of oral hygiene for schoolchildren. The primary focus of the program was a daily “ brush-in,” managed by teachers and parent volunteers. Emphasis was placed on plaque removal in lieu of conceptual-informational con tent, and the role of consultants was to maintain the behavior of participants through occasional visitation and evaluation. Analysis suggested that the program was economical and effective when judged on the basis of typical oral hygiene meas ures. Findings are discussed in terms of the rela tionship between knowledge and behavior, and efficient use of professional time.
The dental health of our children is, of course, a matter of major concern to the dental profession. Unfortunately, attempts to improve preventive dental practices among children, especially in schools, have often met with frustration. The re quirements that programs be easily managed, acceptable to parents, and effective—all within the limits of economic feasibility—have been difficult to accomplish. We have initiated, over a three-year period, a pilot dental health project that seems to meet the criteria just mentioned. The project is based on active, preventive beha vior developed and maintained by parents, teach ers, and the children themselves.
R ationale
Health education programs have typically been aimed at the provision of information, even though it has been known for some years that appropriate behavior, rather than knowledge, per se, is required to preserve health.1 For example, many persons are aware of the dangers of smok ing, but find themselves unable to quit; and many understand the significance of oral hygiene, but do not practice effective measures. Program evaluation must therefore rest with behavioral outcomes, not knowledge.2 A major problem in implementation of an ef fective school dental hygiene program is the ar rangement of an effective consultation proce dure. This is important in the achievement of program quality, as well as for maintenance of behavior over time. For such a strategy, one must JA D A , V o l. 94, J u n e 1977 ■ 1183
OBJECTIVE
PRINCIPLE
ACTIVITY
Student will be able to:
Fig 1 ■ Triadic model from Tharp and Wetzel.
look to the technology of behavior. One such ap proach is the triadic model for consultation, de scribed by Tharp and Wetzel.3 This model (Fig 1) is an alternative to the traditional doctor-patient dyad, and contains the following components: target(s) (anyone with a problem), mediators) (anyone with the reinforcers, that is, the ability to control behavior of the target); and consultant(s) (anyone with the knowledge). In the program described here, targets were schoolchildren, mediators were teachers and parent volunteers, and consultants were three faculty of the Univer sity of Nebraska College of Dentistry.
Materials and methods ■ Program : The program used in the present study was one we wrote and adopted for use in Nebraska public schools.4 Each level of this el ementary school curriculum was divided into objectives, principles, and suggested teaching activities. The objectives were statements of learner outcomes, the principles were statements of fact that gave rise to particular objectives, and the teaching activities were suggested ways to achieve the objectives. While the program contained some cognitive objectives and sug gestions for ancillary activities, primary empha sis was on daily disclosure and removal of bac terial plaque. This daily activity was designated the “brush-in.” A sample of the curriculum, from the kindergarten level, appears in Figure 2. ■ Participants: This curriculum was implem ented in a small elementary school near Lincoln, Neb, on a sequential basis. In fall 1973, grades kindergarten through two began participation in the program. These students, as well as each new kindergarten class, continued to the present time. Thus, at this writing, the preventive pro gram has been fully implemented for grades kin dergarten through four, a total of 41 children. The program was initially managed by a parent volunteer and has since been maintained by teachers with parental assistance. 1184 ■ JADA, Vol. 94, June 1977
1. Show how teeth bite and chew.
1. Teeth are necessary to cut.
1. Bite apple and chew celery.
2. Count teeth using a mirror and cotton swab.
2. Early develop ment of eye-hand coordination is necessary for fu ture dental health care procedure.
2. Teacher counts own teeth; child counts own teeth using mirror and swab.
3. Stain the teeth to show where germs grow.
3. Invisible germs cause disease; staining makes them visible.
3. Teacher stains own teeth; children stain their teeth. using disclosing tablet.
4. Brush the red stain away.
4. Daily removal of germs by brush ing will help to prevent disease.
4. Daily staining and “brush-in" at same time each day.
Fig 2 ■ Sam ple of preventive dental program from kindergarten level.
■ M aterials: The following materials were made available for each child for the daily “brushin” : —Soft-bristled toothbrush, with a cap to cover the bristles when not in use. —Disclosing tablets; a half tablet per child per day was typically sufficient. —Paper cup (used as a receptacle for residue of tablet and for excess saliva). —Napkin or paper towel (to wipe the mouth and, if necessary, to tuck in the collar to serve as a bib). —Small, hand-held mirror (doll-size, two to three inches in diameter). Total cost of these materials per child per school year (including replacement brushes) was approximately $2.75. ■ Evaluation: At seven times during the three academic years from 1973 to 1976, subgroups (or the total study population) of students were screened with one or more measures. Data were collected on an oral hygiene index, a gingival index, and a visual count of carious teeth. The oral hygiene index was a modification of the simplified Oral Hygiene Index developed by Greene and Vermillion* and was designated the OHI-M. It involved scoring debris on six man dibular and six maxillary teeth on a continuum from zero (no debris) to three (debris covering two thirds or more of the tooth), with a possible total score ranging from zero to 36. The index was computed by dividing the total score by the number of teeth scored.
0.8GRADE1 (N=10) 0.7- —
x 0.4Û “ 0.3£ i 0.2ca 0.1-
PR0GRAMBEGINS 1NOVEMBER 1973 j |
0.6-
KINDERGARTENX g 0.5- - (N*8) V j \ z RADE2
0.0
\
o.o-
“ brush-in” group (K-4) and “ nonbrush-in” group (5-8).
I 11 OCTOBER 1973
\
MAY 1975
SEPTEMBER APRIL 1975 1976
Fig 3 ■ D evelopm ent and m aintenance of oral hygiene as indi cated by gingival indices fo r original "brush-in" group.
The gingival index we used was that of Loe,6 adapted to a sample of six mandibular and six maxillary teeth. The criteria used were those specified by Loe, with possible scores ranging from zero (normal) to three (severe inflamma tion). Loe has indicated that participants who have mild inflammation generally have scores ranging from 0.1-1.0; with moderate inflamma tion, 1.1-2.0; and with severe inflammation, 2.13.0.« The visual count of carious teeth was accom plished by use of tongue blades and a handheld light, in the students’ classrooms. This was, of course, not a thorough examination, but simply a cursory screening.
Fig 4 ■ Progress o f an entering kindergarten group in “brushin ” program .
GRADES K-4. DAILYBRUSH-IN (N*41-49) i i SEPTEMBER APRIL 1975 1976
Fig 5 ■ M ean gingival indices for 1 97 5-1976 school year for
¡5 0.20.1-
GRADES5-8, NO BRUSH-IN, OCCASIONAL FLOSSING(N-44-49)
Results The progress of the original kindergarten, first, and second grade groups through three academic years in the program is shown in Figure 3. It may be seen that all groups have moved steadily to levels that approach the virtual absence of visi ble inflammation. When a typical kindergarten group is followed from entry point to the time of this writing, the result is another set of similar curves (Fig 4), not only for the gingival index, but for the OHI-M and the number of carious teeth, as well. It may be argued, of course, that these data would improve naturally with the maturation and improved coordination of children as they become older. In order to examine this possibil ity, same-day gingival indices were made for all children in the school at two dates during the 1975-1976 academic year (Fig 5). At that time grades kindergarten through four were involved in the “brush-in” program, while grades five through eight, although occasionally flossing at school, were not. These data suggest that the process of growing older did not alone account for the changes evident in the program. A final measure of interest has been the de cline in number of obviously carious teeth among the children (Fig 4, 6). While the oral hy giene program, per se, has certainly not pro duced a decrement in carious teeth (and a num ber of carious deciduous teeth have no doubt been lost), the interest shown in the program by parents has been substantial. Accordingly, it is safe to assume that the children are now receiv ing a higher level of professional dental care than formerly. That is, the number of carious lesions declines as more frequent treatment is sought.
Keith— W entz— W ood: O RAL H Y G IE N E P R O G R A M FOR SC HO O LC H ILD R E N ■ 1185
z>— LU w 2.fl eo 3 O DC 1.5-< O u. O 1.0- 1LC U m s3 0.5 Z Z < LU 2
PROGRAMBEGINS NOVEMBER 1973
ORIGINAL*4 BRUSH-IN GROUP (N*30-31) OCTOBER 1973
CURRENT K-2 IN BRUSH-INPROGRAM . (N=22)
Second, the program tends to confirm the im portance of a systematic consultation role as a useful application of professional time. An equiv alent (or larger) investment of time could easily be made in addressing groups or showing films during Dental Health Week, but without an ac companying change in consumer behavior. When the consultant adopts the goal of effecting productive teacher (or parent or principal) beha vior change, resultant changes in the practices of children are virtually inevitable.
SEPTEMBER 1975
Fig 6 ■ M ean num ber o f carious teeth fo r original K-2 "brush-in" grou p before onset o f program and tw o years after, and for cur rent K-2 group in th e program .
Dr. Keith is coordinator of research, Fam ily R ehabilitation Pro gram , M eyer C hildren's Rehabilitation Institute of th e University o f N ebraska M edical C enter, 444 S 44th St, O m aha, 68131. Dr. Keith also is assistant professor, departm ent of preventive den tistry and com m unity health, University o f N ebraska C ollege of Dentistry. Dr. W entz is assistant dean, director o f graduate and
Discussion The program described here is considered note worthy for two reasons. First, it is a behaviorbased undertaking that directly attacks the prob lems of establishing and maintaining preventive oral health skills. There are broad discrepancies between what is known and what is practiced. A recent study, for example, showed that 70% to 80% of American smokers agree that smoking may be harmful and that 90% would like to quit, but that 57% expect to be smoking five years hence.7 The “brush-in” program is predicated on the assumption that behavior change must be achieved before (or concurrent with) chang es in attitudes or verbal behavior.
1186 ■ JADA, Vol. 94, June 1977
continuing education, and professor of periodontics, and Dr. W ood is chairm an and associate professor, d epartm ent of pre ventive dentistry and com m unity health, University o f Nebraska C olleg e of Dentistry at Lincoln. Address requests fo r reprints to Dr. Keith. 1. Cassidy, J.E. Principles of behavior. Paper presented in course on technics for consultants in a dental health education program for upper elem entary school systems. C leveland, 1972. 2. Greene, J.C., and Verm illion, J.R. Oral hygiene research and im plications for periodontal care. J D ent Res 50:184 M archApril 1971. 3. Tharp, R.G., and W etzel, R.J. Behavior m odification in the natural environm ent. N ew York, A cadem ic Press, 1969. 4. D ental health care: a teacher resource. N ebraska Depart m en t o f E ducation. Lincoln, Neb, 1974. 5. Greene, J.C., and Verm illion, J.R. Th e sim plified Oral Hygiene Index Systems. JADA 68:7 Jan 1964. 6. LOe, H. The Gingival Index, th e Plaque Index and th e R eten tion In dex Systems. J P eriodont 38:610 Nov-Dee 1967. 7. A dult use of tobacco— 1975. N ebraska Div., Inc., American C an cer Society. Om aha, 1976.
A practical, behavior-based oral hygiene program for elementary school children
K e n n e th D. K e ith , F ra n k M . W e n tz, R o b e rt M . W oo d,
PhD, Omaha
DDS, PhD DDS, Lincoln, Neb
A three-year study was made of the effectiveness of a behavior-based program of oral hygiene for schoolchildren. The primary focus of the program was a daily “ brush-in,” managed by teachers and parent volunteers. Emphasis was placed on plaque removal in lieu of conceptual-informational con tent, and the role of consultants was to maintain the behavior of participants through occasional visitation and evaluation. Analysis suggested that the program was economical and effective when judged on the basis of typical oral hygiene meas ures. Findings are discussed in terms of the rela tionship between knowledge and behavior, and efficient use of professional time.
The dental health of our children is, of course, a matter of major concern to the dental profession. Unfortunately, attempts to improve preventive dental practices among children, especially in schools, have often met with frustration. The re quirements that programs be easily managed, acceptable to parents, and effective—all within the limits of economic feasibility—have been difficult to accomplish. We have initiated, over a three-year period, a pilot dental health project that seems to meet the criteria just mentioned. The project is based on active, preventive beha vior developed and maintained by parents, teach ers, and the children themselves.
R ationale
Health education programs have typically been aimed at the provision of information, even though it has been known for some years that appropriate behavior, rather than knowledge, per se, is required to preserve health.1 For example, many persons are aware of the dangers of smok ing, but find themselves unable to quit; and many understand the significance of oral hygiene, but do not practice effective measures. Program evaluation must therefore rest with behavioral outcomes, not knowledge.2 A major problem in implementation of an ef fective school dental hygiene program is the ar rangement of an effective consultation proce dure. This is important in the achievement of program quality, as well as for maintenance of behavior over time. For such a strategy, one must JA D A , V o l. 94, J u n e 1977 ■ 1183
OBJECTIVE
PRINCIPLE
ACTIVITY
Student will be able to:
Fig 1 ■ Triadic model from Tharp and Wetzel.
look to the technology of behavior. One such ap proach is the triadic model for consultation, de scribed by Tharp and Wetzel.3 This model (Fig 1) is an alternative to the traditional doctor-patient dyad, and contains the following components: target(s) (anyone with a problem), mediators) (anyone with the reinforcers, that is, the ability to control behavior of the target); and consultant(s) (anyone with the knowledge). In the program described here, targets were schoolchildren, mediators were teachers and parent volunteers, and consultants were three faculty of the Univer sity of Nebraska College of Dentistry.
Materials and methods ■ Program : The program used in the present study was one we wrote and adopted for use in Nebraska public schools.4 Each level of this el ementary school curriculum was divided into objectives, principles, and suggested teaching activities. The objectives were statements of learner outcomes, the principles were statements of fact that gave rise to particular objectives, and the teaching activities were suggested ways to achieve the objectives. While the program contained some cognitive objectives and sug gestions for ancillary activities, primary empha sis was on daily disclosure and removal of bac terial plaque. This daily activity was designated the “brush-in.” A sample of the curriculum, from the kindergarten level, appears in Figure 2. ■ Participants: This curriculum was implem ented in a small elementary school near Lincoln, Neb, on a sequential basis. In fall 1973, grades kindergarten through two began participation in the program. These students, as well as each new kindergarten class, continued to the present time. Thus, at this writing, the preventive pro gram has been fully implemented for grades kin dergarten through four, a total of 41 children. The program was initially managed by a parent volunteer and has since been maintained by teachers with parental assistance. 1184 ■ JADA, Vol. 94, June 1977
1. Show how teeth bite and chew.
1. Teeth are necessary to cut.
1. Bite apple and chew celery.
2. Count teeth using a mirror and cotton swab.
2. Early develop ment of eye-hand coordination is necessary for fu ture dental health care procedure.
2. Teacher counts own teeth; child counts own teeth using mirror and swab.
3. Stain the teeth to show where germs grow.
3. Invisible germs cause disease; staining makes them visible.
3. Teacher stains own teeth; children stain their teeth. using disclosing tablet.
4. Brush the red stain away.
4. Daily removal of germs by brush ing will help to prevent disease.
4. Daily staining and “brush-in" at same time each day.
Fig 2 ■ Sam ple of preventive dental program from kindergarten level.
■ M aterials: The following materials were made available for each child for the daily “brushin” : —Soft-bristled toothbrush, with a cap to cover the bristles when not in use. —Disclosing tablets; a half tablet per child per day was typically sufficient. —Paper cup (used as a receptacle for residue of tablet and for excess saliva). —Napkin or paper towel (to wipe the mouth and, if necessary, to tuck in the collar to serve as a bib). —Small, hand-held mirror (doll-size, two to three inches in diameter). Total cost of these materials per child per school year (including replacement brushes) was approximately $2.75. ■ Evaluation: At seven times during the three academic years from 1973 to 1976, subgroups (or the total study population) of students were screened with one or more measures. Data were collected on an oral hygiene index, a gingival index, and a visual count of carious teeth. The oral hygiene index was a modification of the simplified Oral Hygiene Index developed by Greene and Vermillion* and was designated the OHI-M. It involved scoring debris on six man dibular and six maxillary teeth on a continuum from zero (no debris) to three (debris covering two thirds or more of the tooth), with a possible total score ranging from zero to 36. The index was computed by dividing the total score by the number of teeth scored.
0.8GRADE1 (N=10) 0.7- —
x 0.4Û “ 0.3£ i 0.2ca 0.1-
PR0GRAMBEGINS 1NOVEMBER 1973 j |
0.6-
KINDERGARTENX g 0.5- - (N*8) V j \ z RADE2
0.0
\
o.o-
“ brush-in” group (K-4) and “ nonbrush-in” group (5-8).
I 11 OCTOBER 1973
\
MAY 1975
SEPTEMBER APRIL 1975 1976
Fig 3 ■ D evelopm ent and m aintenance of oral hygiene as indi cated by gingival indices fo r original "brush-in" group.
The gingival index we used was that of Loe,6 adapted to a sample of six mandibular and six maxillary teeth. The criteria used were those specified by Loe, with possible scores ranging from zero (normal) to three (severe inflamma tion). Loe has indicated that participants who have mild inflammation generally have scores ranging from 0.1-1.0; with moderate inflamma tion, 1.1-2.0; and with severe inflammation, 2.13.0.« The visual count of carious teeth was accom plished by use of tongue blades and a handheld light, in the students’ classrooms. This was, of course, not a thorough examination, but simply a cursory screening.
Fig 4 ■ Progress o f an entering kindergarten group in “brushin ” program .
GRADES K-4. DAILYBRUSH-IN (N*41-49) i i SEPTEMBER APRIL 1975 1976
Fig 5 ■ M ean gingival indices for 1 97 5-1976 school year for
¡5 0.20.1-
GRADES5-8, NO BRUSH-IN, OCCASIONAL FLOSSING(N-44-49)
Results The progress of the original kindergarten, first, and second grade groups through three academic years in the program is shown in Figure 3. It may be seen that all groups have moved steadily to levels that approach the virtual absence of visi ble inflammation. When a typical kindergarten group is followed from entry point to the time of this writing, the result is another set of similar curves (Fig 4), not only for the gingival index, but for the OHI-M and the number of carious teeth, as well. It may be argued, of course, that these data would improve naturally with the maturation and improved coordination of children as they become older. In order to examine this possibil ity, same-day gingival indices were made for all children in the school at two dates during the 1975-1976 academic year (Fig 5). At that time grades kindergarten through four were involved in the “brush-in” program, while grades five through eight, although occasionally flossing at school, were not. These data suggest that the process of growing older did not alone account for the changes evident in the program. A final measure of interest has been the de cline in number of obviously carious teeth among the children (Fig 4, 6). While the oral hy giene program, per se, has certainly not pro duced a decrement in carious teeth (and a num ber of carious deciduous teeth have no doubt been lost), the interest shown in the program by parents has been substantial. Accordingly, it is safe to assume that the children are now receiv ing a higher level of professional dental care than formerly. That is, the number of carious lesions declines as more frequent treatment is sought.
Keith— W entz— W ood: O RAL H Y G IE N E P R O G R A M FOR SC HO O LC H ILD R E N ■ 1185
z>— LU w 2.fl eo 3 O DC 1.5-< O u. O 1.0- 1LC U m s3 0.5 Z Z < LU 2
PROGRAMBEGINS NOVEMBER 1973
ORIGINAL*4 BRUSH-IN GROUP (N*30-31) OCTOBER 1973
CURRENT K-2 IN BRUSH-INPROGRAM . (N=22)
Second, the program tends to confirm the im portance of a systematic consultation role as a useful application of professional time. An equiv alent (or larger) investment of time could easily be made in addressing groups or showing films during Dental Health Week, but without an ac companying change in consumer behavior. When the consultant adopts the goal of effecting productive teacher (or parent or principal) beha vior change, resultant changes in the practices of children are virtually inevitable.
SEPTEMBER 1975
Fig 6 ■ M ean num ber o f carious teeth fo r original K-2 "brush-in" grou p before onset o f program and tw o years after, and for cur rent K-2 group in th e program .
Dr. Keith is coordinator of research, Fam ily R ehabilitation Pro gram , M eyer C hildren's Rehabilitation Institute of th e University o f N ebraska M edical C enter, 444 S 44th St, O m aha, 68131. Dr. Keith also is assistant professor, departm ent of preventive den tistry and com m unity health, University o f N ebraska C ollege of Dentistry. Dr. W entz is assistant dean, director o f graduate and
Discussion The program described here is considered note worthy for two reasons. First, it is a behaviorbased undertaking that directly attacks the prob lems of establishing and maintaining preventive oral health skills. There are broad discrepancies between what is known and what is practiced. A recent study, for example, showed that 70% to 80% of American smokers agree that smoking may be harmful and that 90% would like to quit, but that 57% expect to be smoking five years hence.7 The “brush-in” program is predicated on the assumption that behavior change must be achieved before (or concurrent with) chang es in attitudes or verbal behavior.
1186 ■ JADA, Vol. 94, June 1977
continuing education, and professor of periodontics, and Dr. W ood is chairm an and associate professor, d epartm ent of pre ventive dentistry and com m unity health, University o f Nebraska C olleg e of Dentistry at Lincoln. Address requests fo r reprints to Dr. Keith. 1. Cassidy, J.E. Principles of behavior. Paper presented in course on technics for consultants in a dental health education program for upper elem entary school systems. C leveland, 1972. 2. Greene, J.C., and Verm illion, J.R. Oral hygiene research and im plications for periodontal care. J D ent Res 50:184 M archApril 1971. 3. Tharp, R.G., and W etzel, R.J. Behavior m odification in the natural environm ent. N ew York, A cadem ic Press, 1969. 4. D ental health care: a teacher resource. N ebraska Depart m en t o f E ducation. Lincoln, Neb, 1974. 5. Greene, J.C., and Verm illion, J.R. Th e sim plified Oral Hygiene Index Systems. JADA 68:7 Jan 1964. 6. LOe, H. The Gingival Index, th e Plaque Index and th e R eten tion In dex Systems. J P eriodont 38:610 Nov-Dee 1967. 7. A dult use of tobacco— 1975. N ebraska Div., Inc., American C an cer Society. Om aha, 1976.