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Knowledge and Attitudes of Schoolteachers Toward Oral Health Programs and Preventive Dentistry
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What can be done by dentists and dental hygienists who are asked to help plan or participate in school oral health programs?
Knowledge and attitudes of schoolteachers toward oral health programs and preventive dentistry Michael J. Loupe, P h D P. Jean Frazier, M P H
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entists and dental hygienists are often asked to participate in school oral h e a lth p ro g ra m s , e s p e c ia lly at the elementary school level. Schools are ideal sites for preventive programs because services can be made available to all c h il dren, including those who, for a variety of reasons, may not be receiving profes sional care. Schools are also logical sites for the presentation of educational health information. As a result, schoolteachers are often asked to conduct oral health education and to administer preventive services. However, teachers may not be well prepared to teach preventive dentistry. In a study of teachers’ knowledge of preven tive dentistry, M ullins and Sprouse1con cluded that elementary school teachers were ill informed about the details of pre ventive dentistry. They could recognize conventional wisdom but could not ex p la in the rationales for basic recom m e n d a tio n s . Freed a n d G o ld s te in ’s2 analyses of dental information included in college health texts may help to ex p lain this conclusion. They found that the treatment of oral health information was often deficient, inadequate, and even in correct.
A lth ou gh higher education may not adequately prepare teachers for their roles in the oral health instruction of their students, m any school-based programs depend heavily on teachers to conduct
educational lessons and to adm inister selected preventive services (for example, fluoride m outhrinsing, tablet programs, or both).3'7 Given the continuing, im portant role of JADA, Vol. 107, August 1983 ■ 229
A R T IC L E S
Table 1 ■ Distribution of questionnaires and response rates. Sent Preventive program (U of M) (RWJ/AFDH) (County) No preventive program Total returned
1973 Returned
Sent 95
428
teachers in school oral health programs, the objectives of this study were: to assess the oral health knowledge, attitudes, and teaching practices of elementary school teachers; to identify changes in knowl edge, attitudes, or practices of teachers in a period of eight years; and to determine if participation in school programs for the primary prevention of dental caries had any influence on teacher knowledge, at titudes, or teaching practices.
Method S u r v e y d e s ig n a n d s u b je c ts
Data were gathered over eight years as part of three survey research projects. Table 1 shows the number of question naires distributed and the responses re ceived, by year and type of school and by the presence or absence of a program for the primary prevention of dental caries. The questionnaire was distributed in 1973 to all 428 teachers in a Minneapolis suburb to assess their attitudes toward participation in oral health education programs; 266 returned the question naire.8 The questionnaire was next used from 1978 to 1980 to assess the effects on teachers’ attitudes of the presence of a program in which University of Min nesota dental students managed teams of professional and student auxiliary per sonnel in a preventive program in the Minneapolis public schools.9 The ques tionnaire was distributed to all 95 teachers in these schools (75 returned) and to 158 teachers in ten schools where there was no preventive program (71 re turned). In 1981, the questionnaire was admin istered to teachers in two different com prehensive dental caries preventive pro grams in the Minneapolis area. One of these programs was (and is) an ongoing project sponsored by the Hennepin County Dental Program (the county in which Minneapolis is located). The pro gram includes oral health education and fluoride m outhrinsing. Of the 174 teachers in the program who received the questionnaire, 89 returned them. The other program was the Robert Wood Johnson—American Fund for Dental Health (RWJ-AFDH) National Preventive Dentistry Demonstration Program, which 230 ■ JADA, Vol. 107, August 1983
%
62
266 266
158
1978 to 1980 Returned 75
71 146
%
Sent
1981 Returned
%
208
79
45
69 174
44 89
64 51
174
105 238
60
was conducted in some Minneapolis area public and parochial schools for five years. This program included oral health education and clinical examinations in all schools, and in most it included dif ferent combinations of the following pre ventive services: fluoride mouthrinsing, topical fluoride treatments, and pit and fissure sealants. Sixty-nine participating teachers were sent questionnaires and 44 completed and returned them. Teachers were active participants in the educa tional and mouthrinsing aspects of the programs, and each of the two programs carried out inservice education sessions for all participating teachers. The questionnaire was also sent, in 1981, to 174 teachers in schools that had no preventive program but were matched by neighborhood to the county program schools; 105 were returned.
Questionnaire and analyses The 48 items on the questionnaire en compassed five themes: the basic ap proaches and instructional resources used to teach about oral health; teachers’ acceptance of various administrative and instructional responsibilities related to children’s oral health programs; teachers’ perceived preparedness to teach various oral health topics; teachers’ rankings of reasons for maintaining their own per sonal oral hygiene; and teachers’ percep tions of the relative effectiveness of vari ous measures to prevent dental caries. Questions asked respondents to check the answers that applied, in a multiple choice format, or to rate the extent of their agreement with statements on a fivepoint Likert-type scale. Responses to the questions included in each of these five themes were subjected to multivariate analyses of variance (MANOVA) to determine if there were significant differences among the groups in their overall patterns of mean scores. Where the MANOVA was significant (P < .01), specific analyses of variance com parisons were made among the groups to test the following effects, again using an alpha level of .01. T im e
Teachers in 1978 to 1980, in schools with no dental caries preventive program,
returned
442 650 (59%)
were grouped with teachers in the 1981 control schools and were compared witt teachers in similar schools in 1973 to tesl for differences that might be a result oi events or changes in education during this period. P r e s e n c e o f p r e v e n tiv e p r o g r a m s
All teachers in schools without preven tive programs were compared with teachers in schools with preventive pro grams to test for the effects of participa tion in systematic dental caries preven tive programs on the several dependent variables. These variables measured teachers’ practices, knowledge, and at titudes alone; they did not assess the ef fectiveness of the preventive programs in which the schools were participating.
Results T e a c h in g a p p r o a c h e s a n d r e s o u r c e s
The majority of respondents (53%) taught dental health education as a single con centrated unit. A much smaller propor tion (15%) taught dental health topics as a regular part of their programs, and a simi lar proportion (15%) combined these two approaches. Seventeen percent did not teach about oral health at all. There were no significant differences among the teacher groups in the basic approaches used to teach about oral health. Table 2 shows the proportion of teachers who used each of the five re sources listed to teach about oral health. Curriculum guides were used by most teachers, whereas more than a third of all teachers used visits by a dental hygienist or school nurse. Only a few used visits by dentists or field trips in their instruction. The MANOVA showed significant dif ferences among the groups and the uni variate analyses showed that the dif ferences were primarily in the use of a school nurse and classroom visits by a dental hygienist. Both of these personnel resources were used more frequently (P < .001) by teachers in 1973 than by teachers in 1978 to 1981. Teachers in schools with dental caries preventive programs tended to use dental hygienists more often (P < .001) than teachers in schools without dental caries preventive programs.
Perceptions o f resp on sibilitie s Respondents were asked to rate the extent to w h ic h they agreed that teachers sh o uld perform each o f 15 respo nsibilities re lated to school oral h e alth program s. The r a tin g s w ere s c a le d fr o m 1 (stro n g ly agree) to 5 (strongly disagree). Table 3 show s the m ean ratings for each of these responsibilities. M e an values o f less than 3.0 in d icate d agreement w ith the state m ent, a n d m ean values of m ore th a n 3.0 in d icate d disagreem ent w ith the state m ent of responsibility. Teachers tended to d isag re e w it h fiv e o f th e r e s p o n sib ilitie s listed, a ll of w h ic h were a d m inistrative in nature (d istrib u tin g and recording dental he alth cards an d m ak in g parent visits, for exam ple) an d ten de d to agree that they sh o u ld accept the re m ain in g ten responsibilities. O f these ten re s p o n s ib ilitie s , o n e was a d m in is tr a tiv e (refer students w ith dental problem s to the school nurse) a n d the rest were clearly instructional. T he M A N O V A sh o w e d clear d iffe r ences am o ng the groups in their percep tions of teachers’ respo nsibilities. The univariate contrasts sho w ed sig nifican t differences as a fu n c tio n of tim e. Teachers in 1973 agreed m ore strongly w ith seven o f th e 15 r e s p o n s i b il i t ie s t h a n d id teachers w h o were surv eye d betw een 1978 an d 1981. H ow ever, the contrasts show ed that the presence or absence of a d e n ta l ca ries p r e v e n tiv e p r o g r a m at school h a d no sig n ific a n t effect on the teachers’ w illin g n e s s to be responsible for teachin g or a d m in is tra tiv e d u tie s that oral health program s often require.
Perceptions o f preparedness Table 4 shows the percentage of teachers w h o b e lie v e d them se lv e s p rep ared to teach basic de ntal h e alth topics. The per c e n ta g e o f te a c h e rs w h o c o n s id e r e d them selves prepared to teach these topics was h ig h , ran g in g from 70% w h o agreed that they were prep ared to teach oral hygiene skills, to 88% co nsidering th e m selves prepared to teach ab out the rela tio n s h ip of diet to oral health. There were n o s i g n i f i c a n t d if fe r e n c e s b e tw e e n groups.
P e rce ive d reasons f o r p e rs o n a l o ra l hygiene Teachers were asked to rank in order of im po rtance (to them selves), five reasons c o m m o n ly g iv e n for m a in t a in in g per sonal oral hygiene. The m ean ranks are sh o w n in Table 5. R espondents ranked the prevention of tooth decay first, fo l low ed by the prevention o f g in g iv a l dis ease. T here w ere n o s ig n if ic a n t d if ferences am o ng the groups o n these m ean rankings.
Table 2 ■ Percentage of teachers who used certain resources in oral health teaching._____________________________________________________________________ M ANOVA contrasts Resource____________________
Use (%)________ Time________ Program vs no program
Curriculum guides and other resources Dental hygienist visiting your classroom
76
nsd
nsd
39
School nurse
37
1973,* P < .001 1973, P < .001
Program, P < .001 nsd
9
nsd
nsd
1
nsd
nsd
Dentist visiting your classroom Field trips related to dental health instruction
M ANOVA summary. W ilks = .703, F - 7.69, P < .0000. ‘ Teachers in 1973 used this resource more often than teachers in subsequent years.
Table 3 ■ Teachers’ acceptance of responsibilities in school oral health programs (1 = strongly agree to 5 = strongly disagree).________________ AN OVA contrasts Responsibility Have personal pride in oral hygiene to set an example for children to follow Help pupils recognize and appreciate the value of good teeth and their effect on appearance, digestion, and speech Help the child develop awareness of the causes of tooth decay Help the child develop awareness of methods of decay prevention Instruct children in eating habits that m inimize tooth decay Motivate each child to establish good oral hygiene and interest in personal dental health Help child develop friendly attitude toward dentist Refer students w ith dental problems to the nurse Teach students to think critically about advertised material pertaining to dental health Demonstrate proper toothbrushing to the class Administer or recommend appropri ate action in case of accident or dental mishap Distribute and record student’s dental health cards Be certain that all students visit dentist once per year Try to coordinate distribution of dental health cards with the dentist’s schedule Visit parents, when necessary, to followup on child’s dental health progress
Mean rating
Time
Program vs no program
1.33
1973,* P < .01
nsd
1.52
nsd
nsd
1.57
nsd
nsd
1.57
1973, P < .01 nsd
nsd
1.63
1973, P < .01
nsd
1.80
nsd
1.85
1973, P < .01 nsd
2.15
nsd
nsd
2.37
nsd
3.15
1973, P < .01 nsd
3.39
nsd
nsd
3.54
1973, P < .001 nsd
nsd
1.63
4.05 4.52
nsd
nsd
nsd
nsd nsd
1973, P < .001
M AN OVA summary. W ilks = .767, F - 2.01, P < .0001. ‘ Teachers in 1973 agreed more strongly with this responsibility than did teachers in subsequent years.
Table 4 ■ Percentage of teachers who felt prepared to teach various oral health topics. Topic Relating good dental health to proper diet Develop a sense of pride in good oral health Appreciating the services that a dentist can provide Understanding the processes and reasons for tooth decay Increasing proficiency in oral hygiene skills (brushing and flossing)
(% )..... 88 82 81 72 70
M A N O V A summary, W ilks = .944, F = 1.45, P < .07 (nsd).
Loupe-Frazier : ATTITUDES OF TEACHERS TOW ARD ORAL HEALTH PROGRAM S ■ 231
A R T IC L E S
Know ledge o f m ethods to p re v e n t d e n ta l caries Teachers were asked to rate the effective ness in p r e v e n tin g to o th decay of 11 c o m m o n actions (1 = very effective to 5 = very in effective), Table 6 show s these 11 item s listed in de sce nding order o f their m ean ratings. T here se e m e d to be several clu ste rs w ith in these ratings; oral hyg ie ne items (brush, floss, an d rinse) w ere considered m ost effective, fo llo w e d by early dental checkups. Next in rated effectiveness was a cluster of three item s that had sim ila r ratings, in c lu d in g “ d r in k in g flu orid ated w ater,” “ u s in g snack substitutes,” and “ m others d rin k in g m ilk w h ile pregnant. ” F in a lly , three item s, “ c h e w in g sugarless g u m ,” “ u s in g a to o th p ic k ,” an d “ using m o u th w a s h e s ,” were co nsidered to be generally ineffective. There were few d if ferences as a fu n c tio n of tim e an d there was no evidence th at the presence or ab sence of a dental caries preventive p ro gram in the school in flu e n c e d teachers’ perceptions of the effectiveness of these measures. Table 7 lists three a d d itio n a l preven tive m easures: “ p ro fe ssio n ally a p p lie d to p ical flu o rid e s ,” “ flu o rid e m outhrinsi n g , ” a n d “ p it a n d fissu re s e a la n ts .” These item s were ad d e d to the qu e stion n aire in the 1981 data co lle ctio n effort. U n iv ariate analyses o f variance show ed s ig n ific a n t differences betw een teachers w h o were p a rtic ip a tin g an d those w h o were n o t p a rticip a tin g in dental caries preventive activities, as w e ll as betw een teachers pa rtic ip a tin g in the tw o different caries preventive program s [County vs RW J-AFDH). Teachers in schools w ith o u t preventive program s be lieved that flu o ride m o u th rin s in g an d sealants were rela tiv e ly ineffective, w hereas teachers in scho ols w it h d e n ta l caries preve ntive program s believed that these m ethods d id have some sm a ll effects. Teachers in the R W J-A FD H p ro g ra m rated sealants as m ore effective th an d id teachers in the c o u n ty pro gram (where sealants were not used). Teachers in the c o u n ty program rated flu o rid e m o u th rin s in g as a more ef fective procedure th a n d id RW J-AFDH teachers (some o f w h o m were in schools w here rin sin g was n o t used). There were no differences in the ratings observed for professionally a p p lie d to p ic a l fluorides, w h ic h were believed by all groups to be o n ly m oderately effective in preventing tooth decay.
Discussion Findings M a n y elem entary school teachers co n sid ered them selves to be both w illin g and able to participate in school oral health program s, a n d the large m ajority d id , in 232 ■ I ADA, Vol. 107, August 1983
Table 5 ■ Teachers’rankings of reasons for maintaining their own personal oral hygiene. Reasons
Mean ranking
To prevent personal tooth decay To prevent gum disease To enhance your own personal appearance To give your mouth a clean, fresh feeling To set an example for students to follow
1.31 2.07 3.26 3.87 4.37
MANOVA summary, W ilks = .96, F ~ 1.05, P < .39 (nsdj.
Table 6 ■ Teachers’ ratings of the effectiveness of various actions in preventing tooth decay (1 = very effective to 5 = very ineffective). ANOVA contrasts Action Use dental floss at least once per day Brush twice per day with fluoridated toothpaste Rinse mouth with water, after meals, if unable to brush Parent helps child to brush teeth until sufficient dexterity to perform on own is gained Parent takes child to dentist by age 2Vz Drink community fluoridated water Use fruits, popcorn, nuts as snack substitutes Mother should drink lots of m ilk and take vitamin D while pregnant Chew sugarless gum to remove food stuffs when unable to brush Use a toothpick after eating if unable to brush Use mouthwashes regularly
Mean rating
Time
Program vs no program
1.42
nsd
nsd
1.48
nsd
1.50
1978-81,* P < .01 nsd
1.53
nsd
nsd
1.81
nsd
nsd
1.96 2.06
nsd nsd
2.09
nsd 1978-81, P < .01 nsd
3.08
nsd
nsd
3.30
nsd
nsd
3.56
1973, P < .01
nsd
nsd
nsd
M A N O VA summary, W ilks = .710, F « 3.56, P < .0000. ‘ Teachers in 1978-81 rated this procedure as more effective than did teachers in 1973.
T a b le 7 ■ 1981 teachers’ ratings o f the effectiveness of va rio u s actio ns in p re v e n tin g to o th decay (1 = very effective to 5 = very ineffective). ANOVA contrasts Action Have fluoride applied professionally to the teeth Use sodium fluoride mouthrinse in school once per week Have acrylic pit and fissure sealants applied to the teeth
Mean rating
Program vs no program
RWJ/AFDH vs county
2.01
nsd
nsd
2.72
Program,* P < .000 Program, P < .0000
County, P < .0000 RWJ, P < .01
2.95
*Teachers in schools with preventive programs rated this procedure as more effective than did teachers in schools without programs.
fact, participate actively in oral he alth in struction. M o st respondents preferred to teach oral he alth lessons in single, co n centrated u n its, an approach that m ig h t w e ll isolate the topic from its appropriate study as a leg itim ate part of the broader sch o o l c u r r ic u lu m . F urth er, the basic m is in fo rm a tio n h e ld by these teachers about oral he alth raised serious concern about the po tential effects of their teach in g efforts. The study also investigated w hether the passage of tim e or the particip a tio n of teachers in preventive program s affected their oral he alth ed u cation practices, at titudes, kno w led ge , or beliefs. T im e was clearly associated w ith the first tw o of these variables; in 1973, teachers were
m ore lik e ly to accept responsibilities for aspects of school-based oral health pro gram s th an were the teachers in 1978 to 1981. The fin d in g s reported by Boyer10 in 1976 fit in to th is trend. A lth o u g h the cur rent study d id not explore the reasons for such differences, it seems safe to specu late that the general decline in the eco n o m ic h e a lth o f schools a n d the c o n co m itan t increased pressures on teachers (for ex am ple, increased class sizes an d teaching responsibilities) m ay have a d versely affected their w illin g n e ss to take o n a d d itio n a l re sp o n sib ilitie s for oral he alth program s. A lth o u g h teachers’ ac ceptance o f re sp o n sib ilitie s an d class room practices have changed since 1973, their beliefs about preparedness to teach
A R T IC L E S
oral health topics, reasons for m a in ta in in g personal oral hygiene, an d k n o w l edge about the effectiveness o f dental caries prev e ntive m e th o d s a p p a re n tly have not changed. The other in d e p e n d e n t variable, par tic ip a tio n in preventive program s, h a d no effect on teachers’ attitudes tow ard ac c e p tin g re s p o n s ib ility for sch o o l oral he alth activities an d few im p o rta n t ef fects on their actual teachin g practices. M oreover, p a r tic ip a tio n in p re v e n tiv e program s d id not affect teachers’ beliefs ab out the relative effectiveness of dental caries preventive m easures in general. R espondents d id believe that k n o w n de n tal caries preventive m etho ds were more effective if they were used in the program in w h ic h th e ir s c h o o ls p a r tic ip a te d . How ever, they still d id not feel that p ro cedures such as fluo rid e m o u th rin s in g an d p it a n d fissure sealants were as effec tive as oral h yg ie ne practices, dietary measures, or m a k in g early dental visits. A cco rd in g to G oldhaber, “betw een the use of water flu o rid a tio n , to p ical flu o rides, an d p it an d fissure sealants, the vast m ajority of sm ooth surface, p it an d fissure caries can be prevented.” 11 C o n s u m p tio n of flu o r id a te d w ater has been s h o w n countless tim es to be the m ost v aluable dental decay preventive m easure a v a il ab le.12,13 The A m e rican D ental A ssocia tio n considers that: “ F lu o rid a tio n is the single m ost potent p u b lic h e alth measure k n o w n to science for preventing tooth de cay.” 14 U nfortunately, it was considered by respondents in these surveys to be less effective for dental caries prev e ntion th an oral hygiene measures. Perhaps m ost d is concerting about these fin d in g s is that these teachers liv e in a c o m m u n ity where the flu orid e level in the water s u p p ly is adjusted by la w to the o p tim a l level for dental caries prevention an d in a state that has had, for the past 13 years, an ef fe c tiv e ly en force d la w th at m a n d a te s c o m m u n ity water flu o rid a tio n . A lth o u g h these fin d in g s are d is a p p o in tin g , they are n o t necessarily un ex pected, g iv e n n a tio n a l data that d o c u m e n t a decrease over the past 15 years in p u b lic kno w led ge about the purpose of flu o r id a tio n .15,16 It is a p p a r e n t th a t every s u c h p r e v e n tiv e m e th o d requires c o n tin u o u s reinforce m e n t over tim e , th r o u g h the effective ed u cation of new generations. In a d d itio n , respondents show ed clear defects in k no w ledge by not d is c rim in a t in g appropriately betw een m ethods for preventing dental caries an d those spe cific to the prevention of g in g iv itis or pe riod on tal disease; they tended to attri bute great value to oral hygiene strategies for the prevention of tooth decay, rather th a n relating those practices specifically to m a in ta in in g g in g iv a l health. T heoreti cally, at the m ic ro biolog ie level, m e tic u lous oral hyg ie ne sh o u ld control dental
Principles for oral health education ■ A scientific body of knowledge exists about the relative effectiveness and efficiency of methods available to prevent oral diseases, through water fluoridation, self-applied fluorides, professionally applied topical fluorides, pit and fissure sealants, reduced access to sugary snacks, routine professional dental care, and oral hygiene.13,28'30 ■ Oral health education and promotion efforts should be parallel to this body of scientific knowledge; that is, priorities for the educational aspects of preventive programs should be determined by what is known from valid research about how best to protect individuals and the community from experiencing dental caries and gingivitis. ■ Every available preventive measure requires education and reinforcement over time, to assure its continued use, whether it be adequate and appropriate fluoride use, pit and fissure sealants, reduced frequency of snacks, obtaining dental care, or oral hygiene. ■ Educational information about the available preventive procedures should be specific to the known effects of each procedure on each of the two most common oral diseases. ■ In every instance where students participate in a primary dental caries preventive method at school, an educational component should be included for students, school personnel, parents, and community dental professionals to assure understanding of the reasons for the procedures, their benefits, and their limitations. ■ Educational information should not be limited, however, to those preventive procedures included in a specific program, but should emphasize the value of community water fluoridation in all educational programs and at every opportunity: where the water is fluoridated, this may reinforce knowledge, understanding and maintenance of the measure, and where it is not fluoridated, this may encourage its adoption, over time.
caries; how ever, because o f practical lim i tations of m e c h an ica l oral hyg ie ne proce du re s, n e ith e r p e rs o n a l o ra l h y g ie n e alone (w ith o u t a flu o rid e dentifrice), nor oral hygiene in stru ctio n have been effec tive or efficient m e th o d s for preventing tooth decay in school pro gram s.17-20 Oral hyg ie ne practices at school have been s h o w n to be related to decreased plaque an d im pro v ed g in g iv a l h e alth scores, but o n ly un d e r h ig h ly supervised co nd itio ns an d o n ly w h e n the s u p e rv isio n is co n tin u o u s , c o n d itio n s th at are im practical in to d a y ’s schools.21
Im p lic a tio n s a n d recom m endations These fin d in g s in d icate the im po rtance of e d u c a tin g teachers m o re c o m p r e h e n sively about the relative benefits of pre ventive m ethods that the in d iv id u a l can perform at h o m e (oral h yg ie ne proce dures u sin g a flu o rid e dentifrice, use of to p ic a l flu o r id e m o u th r in s e s , k n o w l edgeable dietary selections, for example); that are available at de ntal offices (topical f lu o r id e a p p lic a tio n s , p it a n d fissure sealants, early detection an d treatment, for exam ple); an d that are frequently pro v id e d th ro u g h c o m m u n ity a n d in s titu tio n a l pro gram s (self- applied flu o rid e program s such as tablets or rinses (or both) in school program s, a n d c o m m u n ity water flu o rid a tio n ). Teachers sho uld also be educated ab out the in d iv id u a l be hav iors associated w it h each o f these measures, such as actual use o f the proce dure, asking for or accepting the proce dure, seeking preventive care, p articipat in g in a school program , d rin k in g the wa ter, encouraging p o lic y m akers to adopt flu o rid a tio n , or v o tin g for flu o rid a tio n .
These fin d in g s also in d ic a te a need to educate teachers ab o u t the v alu e of pre ventive procedures be in g used at school. A lth o u g h teachers a n d parents m ay co n sent to a llo w students to participate in school- based p r im a r y p re v e n tiv e ser vices, such org an ized efforts m ay w ane because of a lack of u n d e rsta n d in g an d a la c k o f in c e n t iv e s or r e in f o r c e m e n t th ro u g h ed u catio n ab out the v alu e of the procedures used. T he sam e c o u ld occur w ith regard to w ater flu o rid a tio n . In this sense, a b e hav io ral focus lim ite d to oral h yg ie ne a n d diet practices c o u ld be dys fu n c tio n a l for the long-term acceptance an d use of effective a n d in n o v a tiv e dental caries preventive program s a n d profes sio nal services. W h a t can be do ne by dentists a n d d e n tal hygienists w h o are calle d on to h e lp p la n or to p articipate in school oral he alth program s? S ch o o l program s p ro v id e m u l tip le o p p o rtu n itie s to p ro v id e p rim a ry preventive services22'24 a n d to prepare students (and teachers) to m ake k n o w l edgeable decisions a b o u t oral h e a lth a n d the prev e ntion o f disease n o t o n ly as in form ed in d iv id u a ls , b u t also as future parents, o p in io n leaders, a n d c o m m u n ity de cision m akers.25’27 S ix basic prin c ip le s that de ntal professionals can a p p ly w h e n assisting school pe rso nn el are s h o w n in the Illustration . These prin c ip le s are based on the ob v i ous ed u catio n al needs o f the respondents in the surveys reported here, on fu n d a m e n tal e d u catio n al p rin c ip le s , an d on the basic u n d e rs ta n d in g of the etiology an d p re v e n tio n o f d e n ta l caries. T eachers s h o u ld k n o w th at the etiology of de ntal c a rie s in v o lv e s th re e m a jo r fa c to rs: m ic r o o r g a n is m s ; d ie t c o n t e n t , a n d dietary patterns le a d in g to the p ro d u c tio n
Loupe-Frazier : ATTITUDES OF TEACHERS TOW ARD ORAL HEALTH PROGRAM S ■ 233
A R T IC L E S
of acid by the microorganisms; and a sus ceptible tooth. They should understand that the most effective, efficient, and prac tical methods available today to prevent dental caries are those that operate by making the tooth less susceptible to the disease process, through the use of opti mal systemic and topical fluorides (mainly for smooth tooth surfaces) and pit and fissure sealants (for the occlusal sur faces of teeth, where more than half of all dental caries occur).13,28'30It seems ironic that these preventive strategies were un derstood the least by teachers in the sur veys reported. The effective use of these procedures is highly dependent on public knowledge and acceptance of their use. Full understanding of the optimal, rec ommended uses of fluorides by individu als and in community programs is espe cially critical because of the frequent in volvement of the public in making deci sions about their use.31'33 A major purpose of health education, according to the World Health Organiza tion, is that people learn to control their own community health environments.34 Therefore, children (and their teachers) should be taught the scientific informa tion about important preventive mea sures such as water fluoridation so that they can be informed consumers, voters, and community leaders on programs that affect their health. Similarly, for young sters to learn to become informed con sumers of professional and community services, they should be taught at school about the effectiveness of these proce dures as an integral part of oral health in struction. Teachers cannot assist in de veloping well-informed students if they themselves remain misinformed. There fore, the challenge to dental professionals who are asked to participate in school oral health programs is to accurately inform teachers and to assist them in teaching students about preventive methods that individuals can perform for themselves, those available through professional den tal care, and those most effectively and ef ficiently provided through institutional and community programs.
Summary Because teachers often take on major roles in school dental health programs, three surveys were completed between 1973 and 1981 to measure teachers’ attitudes and knowledge about oral health and their own participation in school pro grams. The questionnaires were sent to teachers whose schools were included in
234 ■ JADA, Vol. 107, August 1983
major dental caries preventive programs and teachers whose schools were not in cluded in such programs. Results showed that: —Teachers were quite willing to teach oral health topics and were willing to take on a wide range of teaching, but not ad ministrative, responsibilities. —Teachers’ acceptance of these re sponsibilities appeared to decrease dur ing the surveys, possibly as a function of school budget difficulties, indicating a need for incentives and positive rein forcement. However, their acceptance of responsibilities was not affected by their participation in preventive programs. —Schoolteachers had basic misinfor mation about the purposes of personal oral hygiene, and about the relative effec tiveness of measures such as oral hygiene and consumption of fluoridated water in preventing dental caries. —The preventive knowledge of teachers was unaffected by either the pas sage of time or participation in school preventive programs. A series of recommendations is given for the inservice education of school teachers.
_________________________ JliOA
The authors thank Dr. Denis Zack and Ms. Carol Kleinhenz of the Minneapolis Health Department, and Drs. Harry Bohannan and Judith Disney of the American Fund for Dental Health’s National Preven tive Dentistry Demonstration Program. Dr. Loupe is professor, and Ms. Frazier is associate professor, department of health ecology, School of Dentistry, University of Minnesota, Health Sciences Unit A, 515 Delaware St SE, Minneapolis, 55455. Ad dress requests for reprints to Dr. Loupe. 1. Mullins, R., and Sprouse, W. Dental health knowledge of elementary school teachers in Bowling Green, Kentucky, 1972. J Am Soc Prev Dent 3(1):6065,1973. 2. Freed, J.R., and Goldstein, M.S. Dental health: what is being taught to college students? JADA 92(5):940-945,1976. 3. Masters, D.H. The classroom teacher . . . effec tive dental health educator. J Am Soc Prev Dent 2:3841,1972. 4. National Dairy Council. Toothtown, USA: pro gram description and unit outline. Chicago, pp 1-27. 5. Stamm, J.W.; Kuo, H.C.; and Neil, D.R. An evaluation of the “Toothkeeper” program in Ver mont. J Public Health Dent 35(2):81-84,1975. 6 . Graves, R.C., and others. A comparison of the ef fectiveness of the “ToothKeeper” and a traditional dental health education program. J Public Health Dent 35(2):85-90,1975. 7. Smith, L.W., and others. Teachers as models in programs for school dental health; an evaluation of “The Toothkeeper”. J Public Health Dent 35(2):75-80, 1975. 8 . King, M.J., and Loupe, M.J. Teachers’ percep tions of responsibility in oral health education.) Dent Res 53 Special Issue (Program and Abstracts) abstract no. 446,166,1974. 9. Loupe, M.J.; McNee, L.; and King, M.J. Teachers’
perceptions of professional responsibility for denti health education. J Dent Res 60 Special Issue A (Pn gram and Abstracts) abstract no. 1239:619,1981. 10. Boyer, M. Classroom teachers’ perceived ro] in dental health education. J Public Health Dei 36(4):237-243, 1976. 11. Goldhaber, P. Implications of technology a! sessment and diffusion for dental research. J Dei Educ 42:646-651,1978. 12. Schrotenboer, G.H. Fluoride benefits—after 3 years. JADA 102(4):473-474,1981. 13. Horowitz, H.S. Established methods of prever tion. Br Dent J 149:311-318,1980. 14. American Dental Association. Dentistry ii health legislation: policies and positions, 1977, p 31 15. United States General Accounting Office. Re ducing tooth decay—more emphasis on fluoridatio] needed. Pub no. HRD-79-3. Washington, DC, Gov eminent Printing Office, 1979, V + 52 p. 16. Frazier, P.J. Fluoridation: a review of social re search. J Pub Health Dent 40:214-233,1980. 17. Carlos, J.P., ed. Prevention and oral health Fogarty International Center Series on Preventivi Medicine, voi 1. Department of Health, Education and Welfare Pub no. (NIH) 74-707,1973. 18. Silverstein, S., and others. Effect of supervisee deplaquing on dental caries, gingivitis and plaque. Dent Res 56 Special Issue A (Program and Abstracts abstract no. 169. 85,1977. 19. Horowitz, A.M., and others. Effects of super vised daily plaque removal by children after thre« years. Community Dent Oral Epidemiol 8:171-176 1980. 20. Heifetz, S.B., and others. Programs for the mass control of plaque, an appraisal. J Public Health Deni 33:2-6, 1975. 21. Horowitz, A.M. Oral hygiene measures. J Canad Dent Assoc 1:43-46,1980. 22. Horowitz, A.M. Preventing tooth decay: a guide for implementing self-applied fluorides in school settings. Department of Health and Human Services, National Institute of Dental Research, Na tional Caries Program, NIH pub no. 82-1196,1981. 23. Horowitz, A.M., and Horowitz, H.S. Schoolbased fluoride programs: a critique. J Prev Dent 6:8994,1980. 24. Kenney, J.B. Thè role and responsibility of schools in affecting dental health status—a potential yet unrealized. J Public Health Dent 39(4):262-267, 1979. 25. Frazier, P.J. A new look at dental health educa tion in community programs. Dent Hygiene 52:176186,1978. 26. Frazier, P.J. School-based instruction for im proving oral health: closing the knowledge gap. Int Dent J 30(3):257-268,1980. 27. Horowitz, A.M., and Frazier, P.J. Effective pub lic education for achieving oral health. J Fam Com munity Health 3(3):91-101,1980. 28. Horowitz, A.M., and Thomas, H.B., eds. Dental caries prevention in public health programs: proceed ings of a conference. Department of Health and Human Services, NIH pub no. 81-2235,1981. 29. Burt, B.A. The relative efficiency of methods of caries prevention in dental public health: workshop summary. J Dent Educ 43:358-362,1979. 30. Silverstone, L.M. The use of pit and fissure sealants in dentistry: present status and future devel opments. Pediatr Dent 4:16-21,1982. 31. Evans, C.A. Challenges to the adoption of community water fluoridation. J Fam Community Health 3(3):33-40,1980. 32. Boriskin, J.M., and Fine, J.I. Fluoridation elec tion victory: a case study for dentistry in effective political action. JADA 102(4):486-491,1981. 33. Isman, R. Fluoridation: strategies for success. Am J Public Health 71(7):717-721,1981. 34. World Health Organization. Health education: a programme review. Offset Pub no. 7, Geneva, 1974.
A
What can be done by dentists and dental hygienists who are asked to help plan or participate in school oral health programs?
Knowledge and attitudes of schoolteachers toward oral health programs and preventive dentistry Michael J. Loupe, P h D P. Jean Frazier, M P H
D
entists and dental hygienists are often asked to participate in school oral h e a lth p ro g ra m s , e s p e c ia lly at the elementary school level. Schools are ideal sites for preventive programs because services can be made available to all c h il dren, including those who, for a variety of reasons, may not be receiving profes sional care. Schools are also logical sites for the presentation of educational health information. As a result, schoolteachers are often asked to conduct oral health education and to administer preventive services. However, teachers may not be well prepared to teach preventive dentistry. In a study of teachers’ knowledge of preven tive dentistry, M ullins and Sprouse1con cluded that elementary school teachers were ill informed about the details of pre ventive dentistry. They could recognize conventional wisdom but could not ex p la in the rationales for basic recom m e n d a tio n s . Freed a n d G o ld s te in ’s2 analyses of dental information included in college health texts may help to ex p lain this conclusion. They found that the treatment of oral health information was often deficient, inadequate, and even in correct.
A lth ou gh higher education may not adequately prepare teachers for their roles in the oral health instruction of their students, m any school-based programs depend heavily on teachers to conduct
educational lessons and to adm inister selected preventive services (for example, fluoride m outhrinsing, tablet programs, or both).3'7 Given the continuing, im portant role of JADA, Vol. 107, August 1983 ■ 229
A R T IC L E S
Table 1 ■ Distribution of questionnaires and response rates. Sent Preventive program (U of M) (RWJ/AFDH) (County) No preventive program Total returned
1973 Returned
Sent 95
428
teachers in school oral health programs, the objectives of this study were: to assess the oral health knowledge, attitudes, and teaching practices of elementary school teachers; to identify changes in knowl edge, attitudes, or practices of teachers in a period of eight years; and to determine if participation in school programs for the primary prevention of dental caries had any influence on teacher knowledge, at titudes, or teaching practices.
Method S u r v e y d e s ig n a n d s u b je c ts
Data were gathered over eight years as part of three survey research projects. Table 1 shows the number of question naires distributed and the responses re ceived, by year and type of school and by the presence or absence of a program for the primary prevention of dental caries. The questionnaire was distributed in 1973 to all 428 teachers in a Minneapolis suburb to assess their attitudes toward participation in oral health education programs; 266 returned the question naire.8 The questionnaire was next used from 1978 to 1980 to assess the effects on teachers’ attitudes of the presence of a program in which University of Min nesota dental students managed teams of professional and student auxiliary per sonnel in a preventive program in the Minneapolis public schools.9 The ques tionnaire was distributed to all 95 teachers in these schools (75 returned) and to 158 teachers in ten schools where there was no preventive program (71 re turned). In 1981, the questionnaire was admin istered to teachers in two different com prehensive dental caries preventive pro grams in the Minneapolis area. One of these programs was (and is) an ongoing project sponsored by the Hennepin County Dental Program (the county in which Minneapolis is located). The pro gram includes oral health education and fluoride m outhrinsing. Of the 174 teachers in the program who received the questionnaire, 89 returned them. The other program was the Robert Wood Johnson—American Fund for Dental Health (RWJ-AFDH) National Preventive Dentistry Demonstration Program, which 230 ■ JADA, Vol. 107, August 1983
%
62
266 266
158
1978 to 1980 Returned 75
71 146
%
Sent
1981 Returned
%
208
79
45
69 174
44 89
64 51
174
105 238
60
was conducted in some Minneapolis area public and parochial schools for five years. This program included oral health education and clinical examinations in all schools, and in most it included dif ferent combinations of the following pre ventive services: fluoride mouthrinsing, topical fluoride treatments, and pit and fissure sealants. Sixty-nine participating teachers were sent questionnaires and 44 completed and returned them. Teachers were active participants in the educa tional and mouthrinsing aspects of the programs, and each of the two programs carried out inservice education sessions for all participating teachers. The questionnaire was also sent, in 1981, to 174 teachers in schools that had no preventive program but were matched by neighborhood to the county program schools; 105 were returned.
Questionnaire and analyses The 48 items on the questionnaire en compassed five themes: the basic ap proaches and instructional resources used to teach about oral health; teachers’ acceptance of various administrative and instructional responsibilities related to children’s oral health programs; teachers’ perceived preparedness to teach various oral health topics; teachers’ rankings of reasons for maintaining their own per sonal oral hygiene; and teachers’ percep tions of the relative effectiveness of vari ous measures to prevent dental caries. Questions asked respondents to check the answers that applied, in a multiple choice format, or to rate the extent of their agreement with statements on a fivepoint Likert-type scale. Responses to the questions included in each of these five themes were subjected to multivariate analyses of variance (MANOVA) to determine if there were significant differences among the groups in their overall patterns of mean scores. Where the MANOVA was significant (P < .01), specific analyses of variance com parisons were made among the groups to test the following effects, again using an alpha level of .01. T im e
Teachers in 1978 to 1980, in schools with no dental caries preventive program,
returned
442 650 (59%)
were grouped with teachers in the 1981 control schools and were compared witt teachers in similar schools in 1973 to tesl for differences that might be a result oi events or changes in education during this period. P r e s e n c e o f p r e v e n tiv e p r o g r a m s
All teachers in schools without preven tive programs were compared with teachers in schools with preventive pro grams to test for the effects of participa tion in systematic dental caries preven tive programs on the several dependent variables. These variables measured teachers’ practices, knowledge, and at titudes alone; they did not assess the ef fectiveness of the preventive programs in which the schools were participating.
Results T e a c h in g a p p r o a c h e s a n d r e s o u r c e s
The majority of respondents (53%) taught dental health education as a single con centrated unit. A much smaller propor tion (15%) taught dental health topics as a regular part of their programs, and a simi lar proportion (15%) combined these two approaches. Seventeen percent did not teach about oral health at all. There were no significant differences among the teacher groups in the basic approaches used to teach about oral health. Table 2 shows the proportion of teachers who used each of the five re sources listed to teach about oral health. Curriculum guides were used by most teachers, whereas more than a third of all teachers used visits by a dental hygienist or school nurse. Only a few used visits by dentists or field trips in their instruction. The MANOVA showed significant dif ferences among the groups and the uni variate analyses showed that the dif ferences were primarily in the use of a school nurse and classroom visits by a dental hygienist. Both of these personnel resources were used more frequently (P < .001) by teachers in 1973 than by teachers in 1978 to 1981. Teachers in schools with dental caries preventive programs tended to use dental hygienists more often (P < .001) than teachers in schools without dental caries preventive programs.
Perceptions o f resp on sibilitie s Respondents were asked to rate the extent to w h ic h they agreed that teachers sh o uld perform each o f 15 respo nsibilities re lated to school oral h e alth program s. The r a tin g s w ere s c a le d fr o m 1 (stro n g ly agree) to 5 (strongly disagree). Table 3 show s the m ean ratings for each of these responsibilities. M e an values o f less than 3.0 in d icate d agreement w ith the state m ent, a n d m ean values of m ore th a n 3.0 in d icate d disagreem ent w ith the state m ent of responsibility. Teachers tended to d isag re e w it h fiv e o f th e r e s p o n sib ilitie s listed, a ll of w h ic h were a d m inistrative in nature (d istrib u tin g and recording dental he alth cards an d m ak in g parent visits, for exam ple) an d ten de d to agree that they sh o u ld accept the re m ain in g ten responsibilities. O f these ten re s p o n s ib ilitie s , o n e was a d m in is tr a tiv e (refer students w ith dental problem s to the school nurse) a n d the rest were clearly instructional. T he M A N O V A sh o w e d clear d iffe r ences am o ng the groups in their percep tions of teachers’ respo nsibilities. The univariate contrasts sho w ed sig nifican t differences as a fu n c tio n of tim e. Teachers in 1973 agreed m ore strongly w ith seven o f th e 15 r e s p o n s i b il i t ie s t h a n d id teachers w h o were surv eye d betw een 1978 an d 1981. H ow ever, the contrasts show ed that the presence or absence of a d e n ta l ca ries p r e v e n tiv e p r o g r a m at school h a d no sig n ific a n t effect on the teachers’ w illin g n e s s to be responsible for teachin g or a d m in is tra tiv e d u tie s that oral health program s often require.
Perceptions o f preparedness Table 4 shows the percentage of teachers w h o b e lie v e d them se lv e s p rep ared to teach basic de ntal h e alth topics. The per c e n ta g e o f te a c h e rs w h o c o n s id e r e d them selves prepared to teach these topics was h ig h , ran g in g from 70% w h o agreed that they were prep ared to teach oral hygiene skills, to 88% co nsidering th e m selves prepared to teach ab out the rela tio n s h ip of diet to oral health. There were n o s i g n i f i c a n t d if fe r e n c e s b e tw e e n groups.
P e rce ive d reasons f o r p e rs o n a l o ra l hygiene Teachers were asked to rank in order of im po rtance (to them selves), five reasons c o m m o n ly g iv e n for m a in t a in in g per sonal oral hygiene. The m ean ranks are sh o w n in Table 5. R espondents ranked the prevention of tooth decay first, fo l low ed by the prevention o f g in g iv a l dis ease. T here w ere n o s ig n if ic a n t d if ferences am o ng the groups o n these m ean rankings.
Table 2 ■ Percentage of teachers who used certain resources in oral health teaching._____________________________________________________________________ M ANOVA contrasts Resource____________________
Use (%)________ Time________ Program vs no program
Curriculum guides and other resources Dental hygienist visiting your classroom
76
nsd
nsd
39
School nurse
37
1973,* P < .001 1973, P < .001
Program, P < .001 nsd
9
nsd
nsd
1
nsd
nsd
Dentist visiting your classroom Field trips related to dental health instruction
M ANOVA summary. W ilks = .703, F - 7.69, P < .0000. ‘ Teachers in 1973 used this resource more often than teachers in subsequent years.
Table 3 ■ Teachers’ acceptance of responsibilities in school oral health programs (1 = strongly agree to 5 = strongly disagree).________________ AN OVA contrasts Responsibility Have personal pride in oral hygiene to set an example for children to follow Help pupils recognize and appreciate the value of good teeth and their effect on appearance, digestion, and speech Help the child develop awareness of the causes of tooth decay Help the child develop awareness of methods of decay prevention Instruct children in eating habits that m inimize tooth decay Motivate each child to establish good oral hygiene and interest in personal dental health Help child develop friendly attitude toward dentist Refer students w ith dental problems to the nurse Teach students to think critically about advertised material pertaining to dental health Demonstrate proper toothbrushing to the class Administer or recommend appropri ate action in case of accident or dental mishap Distribute and record student’s dental health cards Be certain that all students visit dentist once per year Try to coordinate distribution of dental health cards with the dentist’s schedule Visit parents, when necessary, to followup on child’s dental health progress
Mean rating
Time
Program vs no program
1.33
1973,* P < .01
nsd
1.52
nsd
nsd
1.57
nsd
nsd
1.57
1973, P < .01 nsd
nsd
1.63
1973, P < .01
nsd
1.80
nsd
1.85
1973, P < .01 nsd
2.15
nsd
nsd
2.37
nsd
3.15
1973, P < .01 nsd
3.39
nsd
nsd
3.54
1973, P < .001 nsd
nsd
1.63
4.05 4.52
nsd
nsd
nsd
nsd nsd
1973, P < .001
M AN OVA summary. W ilks = .767, F - 2.01, P < .0001. ‘ Teachers in 1973 agreed more strongly with this responsibility than did teachers in subsequent years.
Table 4 ■ Percentage of teachers who felt prepared to teach various oral health topics. Topic Relating good dental health to proper diet Develop a sense of pride in good oral health Appreciating the services that a dentist can provide Understanding the processes and reasons for tooth decay Increasing proficiency in oral hygiene skills (brushing and flossing)
(% )..... 88 82 81 72 70
M A N O V A summary, W ilks = .944, F = 1.45, P < .07 (nsd).
Loupe-Frazier : ATTITUDES OF TEACHERS TOW ARD ORAL HEALTH PROGRAM S ■ 231
A R T IC L E S
Know ledge o f m ethods to p re v e n t d e n ta l caries Teachers were asked to rate the effective ness in p r e v e n tin g to o th decay of 11 c o m m o n actions (1 = very effective to 5 = very in effective), Table 6 show s these 11 item s listed in de sce nding order o f their m ean ratings. T here se e m e d to be several clu ste rs w ith in these ratings; oral hyg ie ne items (brush, floss, an d rinse) w ere considered m ost effective, fo llo w e d by early dental checkups. Next in rated effectiveness was a cluster of three item s that had sim ila r ratings, in c lu d in g “ d r in k in g flu orid ated w ater,” “ u s in g snack substitutes,” and “ m others d rin k in g m ilk w h ile pregnant. ” F in a lly , three item s, “ c h e w in g sugarless g u m ,” “ u s in g a to o th p ic k ,” an d “ using m o u th w a s h e s ,” were co nsidered to be generally ineffective. There were few d if ferences as a fu n c tio n of tim e an d there was no evidence th at the presence or ab sence of a dental caries preventive p ro gram in the school in flu e n c e d teachers’ perceptions of the effectiveness of these measures. Table 7 lists three a d d itio n a l preven tive m easures: “ p ro fe ssio n ally a p p lie d to p ical flu o rid e s ,” “ flu o rid e m outhrinsi n g , ” a n d “ p it a n d fissu re s e a la n ts .” These item s were ad d e d to the qu e stion n aire in the 1981 data co lle ctio n effort. U n iv ariate analyses o f variance show ed s ig n ific a n t differences betw een teachers w h o were p a rtic ip a tin g an d those w h o were n o t p a rticip a tin g in dental caries preventive activities, as w e ll as betw een teachers pa rtic ip a tin g in the tw o different caries preventive program s [County vs RW J-AFDH). Teachers in schools w ith o u t preventive program s be lieved that flu o ride m o u th rin s in g an d sealants were rela tiv e ly ineffective, w hereas teachers in scho ols w it h d e n ta l caries preve ntive program s believed that these m ethods d id have some sm a ll effects. Teachers in the R W J-A FD H p ro g ra m rated sealants as m ore effective th an d id teachers in the c o u n ty pro gram (where sealants were not used). Teachers in the c o u n ty program rated flu o rid e m o u th rin s in g as a more ef fective procedure th a n d id RW J-AFDH teachers (some o f w h o m were in schools w here rin sin g was n o t used). There were no differences in the ratings observed for professionally a p p lie d to p ic a l fluorides, w h ic h were believed by all groups to be o n ly m oderately effective in preventing tooth decay.
Discussion Findings M a n y elem entary school teachers co n sid ered them selves to be both w illin g and able to participate in school oral health program s, a n d the large m ajority d id , in 232 ■ I ADA, Vol. 107, August 1983
Table 5 ■ Teachers’rankings of reasons for maintaining their own personal oral hygiene. Reasons
Mean ranking
To prevent personal tooth decay To prevent gum disease To enhance your own personal appearance To give your mouth a clean, fresh feeling To set an example for students to follow
1.31 2.07 3.26 3.87 4.37
MANOVA summary, W ilks = .96, F ~ 1.05, P < .39 (nsdj.
Table 6 ■ Teachers’ ratings of the effectiveness of various actions in preventing tooth decay (1 = very effective to 5 = very ineffective). ANOVA contrasts Action Use dental floss at least once per day Brush twice per day with fluoridated toothpaste Rinse mouth with water, after meals, if unable to brush Parent helps child to brush teeth until sufficient dexterity to perform on own is gained Parent takes child to dentist by age 2Vz Drink community fluoridated water Use fruits, popcorn, nuts as snack substitutes Mother should drink lots of m ilk and take vitamin D while pregnant Chew sugarless gum to remove food stuffs when unable to brush Use a toothpick after eating if unable to brush Use mouthwashes regularly
Mean rating
Time
Program vs no program
1.42
nsd
nsd
1.48
nsd
1.50
1978-81,* P < .01 nsd
1.53
nsd
nsd
1.81
nsd
nsd
1.96 2.06
nsd nsd
2.09
nsd 1978-81, P < .01 nsd
3.08
nsd
nsd
3.30
nsd
nsd
3.56
1973, P < .01
nsd
nsd
nsd
M A N O VA summary, W ilks = .710, F « 3.56, P < .0000. ‘ Teachers in 1978-81 rated this procedure as more effective than did teachers in 1973.
T a b le 7 ■ 1981 teachers’ ratings o f the effectiveness of va rio u s actio ns in p re v e n tin g to o th decay (1 = very effective to 5 = very ineffective). ANOVA contrasts Action Have fluoride applied professionally to the teeth Use sodium fluoride mouthrinse in school once per week Have acrylic pit and fissure sealants applied to the teeth
Mean rating
Program vs no program
RWJ/AFDH vs county
2.01
nsd
nsd
2.72
Program,* P < .000 Program, P < .0000
County, P < .0000 RWJ, P < .01
2.95
*Teachers in schools with preventive programs rated this procedure as more effective than did teachers in schools without programs.
fact, participate actively in oral he alth in struction. M o st respondents preferred to teach oral he alth lessons in single, co n centrated u n its, an approach that m ig h t w e ll isolate the topic from its appropriate study as a leg itim ate part of the broader sch o o l c u r r ic u lu m . F urth er, the basic m is in fo rm a tio n h e ld by these teachers about oral he alth raised serious concern about the po tential effects of their teach in g efforts. The study also investigated w hether the passage of tim e or the particip a tio n of teachers in preventive program s affected their oral he alth ed u cation practices, at titudes, kno w led ge , or beliefs. T im e was clearly associated w ith the first tw o of these variables; in 1973, teachers were
m ore lik e ly to accept responsibilities for aspects of school-based oral health pro gram s th an were the teachers in 1978 to 1981. The fin d in g s reported by Boyer10 in 1976 fit in to th is trend. A lth o u g h the cur rent study d id not explore the reasons for such differences, it seems safe to specu late that the general decline in the eco n o m ic h e a lth o f schools a n d the c o n co m itan t increased pressures on teachers (for ex am ple, increased class sizes an d teaching responsibilities) m ay have a d versely affected their w illin g n e ss to take o n a d d itio n a l re sp o n sib ilitie s for oral he alth program s. A lth o u g h teachers’ ac ceptance o f re sp o n sib ilitie s an d class room practices have changed since 1973, their beliefs about preparedness to teach
A R T IC L E S
oral health topics, reasons for m a in ta in in g personal oral hygiene, an d k n o w l edge about the effectiveness o f dental caries prev e ntive m e th o d s a p p a re n tly have not changed. The other in d e p e n d e n t variable, par tic ip a tio n in preventive program s, h a d no effect on teachers’ attitudes tow ard ac c e p tin g re s p o n s ib ility for sch o o l oral he alth activities an d few im p o rta n t ef fects on their actual teachin g practices. M oreover, p a r tic ip a tio n in p re v e n tiv e program s d id not affect teachers’ beliefs ab out the relative effectiveness of dental caries preventive m easures in general. R espondents d id believe that k n o w n de n tal caries preventive m etho ds were more effective if they were used in the program in w h ic h th e ir s c h o o ls p a r tic ip a te d . How ever, they still d id not feel that p ro cedures such as fluo rid e m o u th rin s in g an d p it a n d fissure sealants were as effec tive as oral h yg ie ne practices, dietary measures, or m a k in g early dental visits. A cco rd in g to G oldhaber, “betw een the use of water flu o rid a tio n , to p ical flu o rides, an d p it an d fissure sealants, the vast m ajority of sm ooth surface, p it an d fissure caries can be prevented.” 11 C o n s u m p tio n of flu o r id a te d w ater has been s h o w n countless tim es to be the m ost v aluable dental decay preventive m easure a v a il ab le.12,13 The A m e rican D ental A ssocia tio n considers that: “ F lu o rid a tio n is the single m ost potent p u b lic h e alth measure k n o w n to science for preventing tooth de cay.” 14 U nfortunately, it was considered by respondents in these surveys to be less effective for dental caries prev e ntion th an oral hygiene measures. Perhaps m ost d is concerting about these fin d in g s is that these teachers liv e in a c o m m u n ity where the flu orid e level in the water s u p p ly is adjusted by la w to the o p tim a l level for dental caries prevention an d in a state that has had, for the past 13 years, an ef fe c tiv e ly en force d la w th at m a n d a te s c o m m u n ity water flu o rid a tio n . A lth o u g h these fin d in g s are d is a p p o in tin g , they are n o t necessarily un ex pected, g iv e n n a tio n a l data that d o c u m e n t a decrease over the past 15 years in p u b lic kno w led ge about the purpose of flu o r id a tio n .15,16 It is a p p a r e n t th a t every s u c h p r e v e n tiv e m e th o d requires c o n tin u o u s reinforce m e n t over tim e , th r o u g h the effective ed u cation of new generations. In a d d itio n , respondents show ed clear defects in k no w ledge by not d is c rim in a t in g appropriately betw een m ethods for preventing dental caries an d those spe cific to the prevention of g in g iv itis or pe riod on tal disease; they tended to attri bute great value to oral hygiene strategies for the prevention of tooth decay, rather th a n relating those practices specifically to m a in ta in in g g in g iv a l health. T heoreti cally, at the m ic ro biolog ie level, m e tic u lous oral hyg ie ne sh o u ld control dental
Principles for oral health education ■ A scientific body of knowledge exists about the relative effectiveness and efficiency of methods available to prevent oral diseases, through water fluoridation, self-applied fluorides, professionally applied topical fluorides, pit and fissure sealants, reduced access to sugary snacks, routine professional dental care, and oral hygiene.13,28'30 ■ Oral health education and promotion efforts should be parallel to this body of scientific knowledge; that is, priorities for the educational aspects of preventive programs should be determined by what is known from valid research about how best to protect individuals and the community from experiencing dental caries and gingivitis. ■ Every available preventive measure requires education and reinforcement over time, to assure its continued use, whether it be adequate and appropriate fluoride use, pit and fissure sealants, reduced frequency of snacks, obtaining dental care, or oral hygiene. ■ Educational information about the available preventive procedures should be specific to the known effects of each procedure on each of the two most common oral diseases. ■ In every instance where students participate in a primary dental caries preventive method at school, an educational component should be included for students, school personnel, parents, and community dental professionals to assure understanding of the reasons for the procedures, their benefits, and their limitations. ■ Educational information should not be limited, however, to those preventive procedures included in a specific program, but should emphasize the value of community water fluoridation in all educational programs and at every opportunity: where the water is fluoridated, this may reinforce knowledge, understanding and maintenance of the measure, and where it is not fluoridated, this may encourage its adoption, over time.
caries; how ever, because o f practical lim i tations of m e c h an ica l oral hyg ie ne proce du re s, n e ith e r p e rs o n a l o ra l h y g ie n e alone (w ith o u t a flu o rid e dentifrice), nor oral hygiene in stru ctio n have been effec tive or efficient m e th o d s for preventing tooth decay in school pro gram s.17-20 Oral hyg ie ne practices at school have been s h o w n to be related to decreased plaque an d im pro v ed g in g iv a l h e alth scores, but o n ly un d e r h ig h ly supervised co nd itio ns an d o n ly w h e n the s u p e rv isio n is co n tin u o u s , c o n d itio n s th at are im practical in to d a y ’s schools.21
Im p lic a tio n s a n d recom m endations These fin d in g s in d icate the im po rtance of e d u c a tin g teachers m o re c o m p r e h e n sively about the relative benefits of pre ventive m ethods that the in d iv id u a l can perform at h o m e (oral h yg ie ne proce dures u sin g a flu o rid e dentifrice, use of to p ic a l flu o r id e m o u th r in s e s , k n o w l edgeable dietary selections, for example); that are available at de ntal offices (topical f lu o r id e a p p lic a tio n s , p it a n d fissure sealants, early detection an d treatment, for exam ple); an d that are frequently pro v id e d th ro u g h c o m m u n ity a n d in s titu tio n a l pro gram s (self- applied flu o rid e program s such as tablets or rinses (or both) in school program s, a n d c o m m u n ity water flu o rid a tio n ). Teachers sho uld also be educated ab out the in d iv id u a l be hav iors associated w it h each o f these measures, such as actual use o f the proce dure, asking for or accepting the proce dure, seeking preventive care, p articipat in g in a school program , d rin k in g the wa ter, encouraging p o lic y m akers to adopt flu o rid a tio n , or v o tin g for flu o rid a tio n .
These fin d in g s also in d ic a te a need to educate teachers ab o u t the v alu e of pre ventive procedures be in g used at school. A lth o u g h teachers a n d parents m ay co n sent to a llo w students to participate in school- based p r im a r y p re v e n tiv e ser vices, such org an ized efforts m ay w ane because of a lack of u n d e rsta n d in g an d a la c k o f in c e n t iv e s or r e in f o r c e m e n t th ro u g h ed u catio n ab out the v alu e of the procedures used. T he sam e c o u ld occur w ith regard to w ater flu o rid a tio n . In this sense, a b e hav io ral focus lim ite d to oral h yg ie ne a n d diet practices c o u ld be dys fu n c tio n a l for the long-term acceptance an d use of effective a n d in n o v a tiv e dental caries preventive program s a n d profes sio nal services. W h a t can be do ne by dentists a n d d e n tal hygienists w h o are calle d on to h e lp p la n or to p articipate in school oral he alth program s? S ch o o l program s p ro v id e m u l tip le o p p o rtu n itie s to p ro v id e p rim a ry preventive services22'24 a n d to prepare students (and teachers) to m ake k n o w l edgeable decisions a b o u t oral h e a lth a n d the prev e ntion o f disease n o t o n ly as in form ed in d iv id u a ls , b u t also as future parents, o p in io n leaders, a n d c o m m u n ity de cision m akers.25’27 S ix basic prin c ip le s that de ntal professionals can a p p ly w h e n assisting school pe rso nn el are s h o w n in the Illustration . These prin c ip le s are based on the ob v i ous ed u catio n al needs o f the respondents in the surveys reported here, on fu n d a m e n tal e d u catio n al p rin c ip le s , an d on the basic u n d e rs ta n d in g of the etiology an d p re v e n tio n o f d e n ta l caries. T eachers s h o u ld k n o w th at the etiology of de ntal c a rie s in v o lv e s th re e m a jo r fa c to rs: m ic r o o r g a n is m s ; d ie t c o n t e n t , a n d dietary patterns le a d in g to the p ro d u c tio n
Loupe-Frazier : ATTITUDES OF TEACHERS TOW ARD ORAL HEALTH PROGRAM S ■ 233
A R T IC L E S
of acid by the microorganisms; and a sus ceptible tooth. They should understand that the most effective, efficient, and prac tical methods available today to prevent dental caries are those that operate by making the tooth less susceptible to the disease process, through the use of opti mal systemic and topical fluorides (mainly for smooth tooth surfaces) and pit and fissure sealants (for the occlusal sur faces of teeth, where more than half of all dental caries occur).13,28'30It seems ironic that these preventive strategies were un derstood the least by teachers in the sur veys reported. The effective use of these procedures is highly dependent on public knowledge and acceptance of their use. Full understanding of the optimal, rec ommended uses of fluorides by individu als and in community programs is espe cially critical because of the frequent in volvement of the public in making deci sions about their use.31'33 A major purpose of health education, according to the World Health Organiza tion, is that people learn to control their own community health environments.34 Therefore, children (and their teachers) should be taught the scientific informa tion about important preventive mea sures such as water fluoridation so that they can be informed consumers, voters, and community leaders on programs that affect their health. Similarly, for young sters to learn to become informed con sumers of professional and community services, they should be taught at school about the effectiveness of these proce dures as an integral part of oral health in struction. Teachers cannot assist in de veloping well-informed students if they themselves remain misinformed. There fore, the challenge to dental professionals who are asked to participate in school oral health programs is to accurately inform teachers and to assist them in teaching students about preventive methods that individuals can perform for themselves, those available through professional den tal care, and those most effectively and ef ficiently provided through institutional and community programs.
Summary Because teachers often take on major roles in school dental health programs, three surveys were completed between 1973 and 1981 to measure teachers’ attitudes and knowledge about oral health and their own participation in school pro grams. The questionnaires were sent to teachers whose schools were included in
234 ■ JADA, Vol. 107, August 1983
major dental caries preventive programs and teachers whose schools were not in cluded in such programs. Results showed that: —Teachers were quite willing to teach oral health topics and were willing to take on a wide range of teaching, but not ad ministrative, responsibilities. —Teachers’ acceptance of these re sponsibilities appeared to decrease dur ing the surveys, possibly as a function of school budget difficulties, indicating a need for incentives and positive rein forcement. However, their acceptance of responsibilities was not affected by their participation in preventive programs. —Schoolteachers had basic misinfor mation about the purposes of personal oral hygiene, and about the relative effec tiveness of measures such as oral hygiene and consumption of fluoridated water in preventing dental caries. —The preventive knowledge of teachers was unaffected by either the pas sage of time or participation in school preventive programs. A series of recommendations is given for the inservice education of school teachers.
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The authors thank Dr. Denis Zack and Ms. Carol Kleinhenz of the Minneapolis Health Department, and Drs. Harry Bohannan and Judith Disney of the American Fund for Dental Health’s National Preven tive Dentistry Demonstration Program. Dr. Loupe is professor, and Ms. Frazier is associate professor, department of health ecology, School of Dentistry, University of Minnesota, Health Sciences Unit A, 515 Delaware St SE, Minneapolis, 55455. Ad dress requests for reprints to Dr. Loupe. 1. Mullins, R., and Sprouse, W. Dental health knowledge of elementary school teachers in Bowling Green, Kentucky, 1972. J Am Soc Prev Dent 3(1):6065,1973. 2. Freed, J.R., and Goldstein, M.S. Dental health: what is being taught to college students? JADA 92(5):940-945,1976. 3. Masters, D.H. The classroom teacher . . . effec tive dental health educator. J Am Soc Prev Dent 2:3841,1972. 4. National Dairy Council. Toothtown, USA: pro gram description and unit outline. Chicago, pp 1-27. 5. Stamm, J.W.; Kuo, H.C.; and Neil, D.R. An evaluation of the “Toothkeeper” program in Ver mont. J Public Health Dent 35(2):81-84,1975. 6 . Graves, R.C., and others. A comparison of the ef fectiveness of the “ToothKeeper” and a traditional dental health education program. J Public Health Dent 35(2):85-90,1975. 7. Smith, L.W., and others. Teachers as models in programs for school dental health; an evaluation of “The Toothkeeper”. J Public Health Dent 35(2):75-80, 1975. 8 . King, M.J., and Loupe, M.J. Teachers’ percep tions of responsibility in oral health education.) Dent Res 53 Special Issue (Program and Abstracts) abstract no. 446,166,1974. 9. Loupe, M.J.; McNee, L.; and King, M.J. Teachers’
perceptions of professional responsibility for denti health education. J Dent Res 60 Special Issue A (Pn gram and Abstracts) abstract no. 1239:619,1981. 10. Boyer, M. Classroom teachers’ perceived ro] in dental health education. J Public Health Dei 36(4):237-243, 1976. 11. Goldhaber, P. Implications of technology a! sessment and diffusion for dental research. J Dei Educ 42:646-651,1978. 12. Schrotenboer, G.H. Fluoride benefits—after 3 years. JADA 102(4):473-474,1981. 13. Horowitz, H.S. Established methods of prever tion. Br Dent J 149:311-318,1980. 14. American Dental Association. Dentistry ii health legislation: policies and positions, 1977, p 31 15. United States General Accounting Office. Re ducing tooth decay—more emphasis on fluoridatio] needed. Pub no. HRD-79-3. Washington, DC, Gov eminent Printing Office, 1979, V + 52 p. 16. Frazier, P.J. Fluoridation: a review of social re search. J Pub Health Dent 40:214-233,1980. 17. Carlos, J.P., ed. Prevention and oral health Fogarty International Center Series on Preventivi Medicine, voi 1. Department of Health, Education and Welfare Pub no. (NIH) 74-707,1973. 18. Silverstein, S., and others. Effect of supervisee deplaquing on dental caries, gingivitis and plaque. Dent Res 56 Special Issue A (Program and Abstracts abstract no. 169. 85,1977. 19. Horowitz, A.M., and others. Effects of super vised daily plaque removal by children after thre« years. Community Dent Oral Epidemiol 8:171-176 1980. 20. Heifetz, S.B., and others. Programs for the mass control of plaque, an appraisal. J Public Health Deni 33:2-6, 1975. 21. Horowitz, A.M. Oral hygiene measures. J Canad Dent Assoc 1:43-46,1980. 22. Horowitz, A.M. Preventing tooth decay: a guide for implementing self-applied fluorides in school settings. Department of Health and Human Services, National Institute of Dental Research, Na tional Caries Program, NIH pub no. 82-1196,1981. 23. Horowitz, A.M., and Horowitz, H.S. Schoolbased fluoride programs: a critique. J Prev Dent 6:8994,1980. 24. Kenney, J.B. Thè role and responsibility of schools in affecting dental health status—a potential yet unrealized. J Public Health Dent 39(4):262-267, 1979. 25. Frazier, P.J. A new look at dental health educa tion in community programs. Dent Hygiene 52:176186,1978. 26. Frazier, P.J. School-based instruction for im proving oral health: closing the knowledge gap. Int Dent J 30(3):257-268,1980. 27. Horowitz, A.M., and Frazier, P.J. Effective pub lic education for achieving oral health. J Fam Com munity Health 3(3):91-101,1980. 28. Horowitz, A.M., and Thomas, H.B., eds. Dental caries prevention in public health programs: proceed ings of a conference. Department of Health and Human Services, NIH pub no. 81-2235,1981. 29. Burt, B.A. The relative efficiency of methods of caries prevention in dental public health: workshop summary. J Dent Educ 43:358-362,1979. 30. Silverstone, L.M. The use of pit and fissure sealants in dentistry: present status and future devel opments. Pediatr Dent 4:16-21,1982. 31. Evans, C.A. Challenges to the adoption of community water fluoridation. J Fam Community Health 3(3):33-40,1980. 32. Boriskin, J.M., and Fine, J.I. Fluoridation elec tion victory: a case study for dentistry in effective political action. JADA 102(4):486-491,1981. 33. Isman, R. Fluoridation: strategies for success. Am J Public Health 71(7):717-721,1981. 34. World Health Organization. Health education: a programme review. Offset Pub no. 7, Geneva, 1974.