- Email: [email protected]
The influence of motivation on a plaque control program for handicapped children
'
B R IE F
reference SLS diet. The difference be tween the cariogenicity of these products and the other snack foods could be attrib uted to the additional cariostatic ingre dients (milk, peanuts, or cocoa, or all three), in addition to alterations in the other physical parameters of foods, as previously mentioned.
Summary The use of the animal model and the Konig-Hofer program-feeding machine is a valuable tool in the research effort to identify the factors contributing to dental caries. As this methodology provides uniform host, microflora, and frequency components, the food is the variable being evaluated. The relative cariogenicity of food is de pendent on variations in the composition, texture, solubility, retentiveness, and ability to stimulate saliva flow. The re sults of these experiments indicated the equal importance of all food-related pa rameters on dental caries formation. If the composition of foods was solely respon sible for dental caries formation, all three of the granola bars should have had simi lar relative cariogenicity values. This was not true. Granola bar no. 3, which was crispier in texture and less moist, had a third the relative cariogenicity value of granola bars nos. 1 and 2. As reported by other d e n ta l re searchers, the production of dental caries
is food related, but not simplistic in na ture. Dental caries is the outcome of com plicated interactions, all of which are equally important in the progress of this ________________________ J'A O A diseaseThis study was done by Hershey Foods Corp. The authors thank Donna M. Boltz and Deborah K. Keiper for their technical assistance. Mr. Morrissey is senior scientist; Mr. Burkholder is a scientist, nutrition research; and Dr. Tarka is direc tor, Life Sciences Research, Hershey Foods Corp, Technical Center, 1025 Reese Ave, Box 805, Hershey, PA 17033-0805. Address requests for reprints to Dr. Tarka. 1. Alfano, M.C. Dental caries: the nature of the problem. Cereal Foods World 26(l):5-9, 1981. 2. Newbrun, E. Sugar and dental caries. Clin Pre vent Dent 4(3):11-14, 1982. 3. Bowen, W.H., and others. A method to assess cariogenic potential of foodstuffs. JADA 107(4):677681, 1980. 4. vanHoute, J., and others. Role of sucrose in col onization of Streptococcus mutans in conventional Sprague-Dawley rats. J Dent Res 55(2):202-215,1976. 5. Fitzgerald, R.J., and Fitzgerald, D.B. The micro biological status of test animals in relation to caries research. In Tanzer, J.M., ed. Proceedings, sym posium on animal models in cariology. Microbiol Abstr (Special Suppl), 1981, pp 89-95. 6. Navia, J.M. Evaluation of nutritional and dietary factors that m odify an im a l caries. J Dent Res 49(6):1213-1227, 1970. 7. Navia, J.M., and Lopez, H. Rat caries assay of reference foods and sugar containing snacks. J Dent Res 62(8):893-898, 1983. 8. Keyes, P.H. Dental caries in the molar teeth of rats. A method for diagnosing and scoring several types of lesions simultaneously. J Dent Res 37:10881099, 1958.
REPORTS
9. Larson, R.H. Merits and modifications of scoring rat dental caries by Keyes method. In Tanzer, J.M., ed. Proceedings, symposium on anim al models in cariol ogy. Microbiol Abstr (Special Suppl), 1981, pp 195203. 10. Schalm, O.W.; Jain, N.C.; and Carroll, E.J. Vet erinary hematology, ed 3. P h ila d e lp h ia , Lea & Febiger, 1974, pp 239-240. 11. Guzzenheim, B.; Schmid, R.; and Muhlemann, H.R. Programmed feeding. In Tanzer, J.M., ed. Pro ceedings, symposium on animal models in cariology. Microbiol Abstr (Special Suppl), 1981, pp 391-401. 12. Gustafsson, B.E., and others. The Vipeholm dental caries study. The effect of different levels of carbohydrate intake on caries activity in 436 indi viduals observed for five years. Acta Odontol Scand 11:232-364, 1954. 13. Stralfors, A. Inhibition of hamster caries by cocoa. The effect of whole and defatted cocoa, and the absence of activity in cocoa fat. Arch Oral Biol 11:149-161, 1966. 14. Stephan, R.M. Effects of different types of hum an foods on dental health in experimental ani mals. J Dent Res 45(5):1551-1561, 1966. 15. Jenkins, G.N. Enamel protective factors in food. J Dent Res 49(6):1318-1325, 1970. 16. Sreebny, L.M. Cariogenicity of cereal grains. C om m unity Dent Oral Epidem iol 11(3):148-155, 1983. 17. Caldwell, R.C. Physical properties of foods and th e ir caries-producing p o te n tia l. J D ent Res 49(6):1293-1299, 1970. 18. Nizel, A.E. Dental caries: protein, fats, and car bohydrates. NY State Dent J 35:71-81, 1969. 19. Mandel, I.D. Diet and dental decay. Nutr Health 2(3):l-6, 1980. 20. DePaola, D.P., and Alfano, M.C. Diet and oral health. Nutr Today 12(3):6-11; 29-32, 1977. 21. Adams, C.F. N utritive value of American foods— in common units. Agriculture handbook no. 456. Washington, DC, US Department of Agriculture, 1975. 22. Weiss, M.E., and Bibby, B.G. Some protein ef fects on enamel solubility. Arch Oral Biol 11:59-63, 1966.
The influence of motivation on a plaque control program for handicapped children Richard D. Udin, DDS Curtis G. Kuster, DDS, M S
i >' iscussions about the dental needs of the handicapped population have ap peared frequently in the dental literature and were reviewed by Nowak.1 In iden tifying these needs, studies have focused on the problems of the patient who lives in an institution. Svatun and Gjermo2 studied such a population (aged 5 to 45) in Norway and found that the oral hygiene and periodontal health were generally poor. Powell,3 in studying an
institutionalized sample, found that the level of oral hygiene was related to the degree of mental retardation. These studies point to the need for pre ventive programs geared for this popula tio n . These p ro g ra m s , w h e n im plemented for patients who are living in institutions, have generally taken one of two forms. The first involves training the patients to care for their own teeth and the second involves the training and motiva tion of the attendants to provide this care. The former was studied by Peterson and others.4 The authors appealed to the van ity of 15 trainable, mentally handicapped males to gain im provem ent in oral hygiene scores. Kass5 had attendants teach and motivate m entally h a n d i capped young adults in proper oral
hygiene techniques, which led to an im provement of hygiene level. By making the attendants responsible for the patients’ plaque removal, Full and others6 were able to demonstrate effec tiveness. In a study by Goyings and Riekse,7 the investigators were able to im prove pe rio do n tal c o n d itio n s by brushing the patients’ teeth twice a day. Many of the mentally and physically h an d icap pe d p o p u la tio n have been moved out of institutions and into com munities in which group and nursing homes, vocationally oriented residences, or families have taken over the care. As a part of this norm alization and dein stitutionalization process, Public Law 94-142 (the Education for A ll H andi capped Children Act of 1975, 20 USC
Udin-Kuster : PLAQUE CONTROL PROGRAM FOR HANDICAPPED CHILDREN ■ 591
BRIEF
REPORTS
1401) was passed, which ensures that each handicapped child receives educa tional services from school age to age 21. These services may be provided by the public school system or contracted to pri vate, government-supported facilities. Also, dental care and prevention, instead of being provided within the institution, are now provided within the community. The special education teachers, who are charged with the training and care of these children, are in a position in which oral hygiene maintenance could be in corporated into the daily classroom routine. In many instances, this has not occurred. Price8 asserts that any dental health education program for people with handicaps should start with inservice education for the classroom teachers. In deed, these individuals are in an excel lent position to instruct the handicapped child in proper oral health maintenance or to provide this care. Yet, according to Leary and Zucker,9 special education teachers an d therapists are seldom trained to administer oral hygiene in struction. These authors showed that dental students were able to teach adoles cents who have cerebral palsy to brush at a special education center. Also, in studies by Schwartz and others10and A l bino and others,11 dental personnel were able to teach severely handicapped chil dren to brush their teeth in the classroom. The purpose of this study was to deter mine whether special education teachers and aides/technicians could improve the oral hygiene of a group of profoundly handicapped children after the children received training in techniques and whether this improvement could be af fected by motivation.
Methods Thirty profoundly, m u ltiply im paired pre school and school-age children were in itially selected to participate in this study. AH sub jects were enrolled in the Multi-handicapped Childrens’ Program at the Hattie B. Monroe Pavilion of the Meyer Childrens’ Rehabilita tion Institute. This program provides an educa tional environment for the children and also serves to train professionals from various dis ciplines. Three subjects were elim inated from the study because of significant absences from school. The participants ranged in age from 3 to 17 years w ith cognitive abilities ranging from birth to 3 years. M any children also had severe sensory and motor disabilities w ith few self-help skills. There were 19 males and 8 females. In the in itia l phase of the study, the authors inform ed the classroom teachers and aides that the children in their class w ould be involved in a study to test the effectiveness of toothbrushing by the teachers in reducing the plaque in the children’s mouths, and that these children w ould participate w ith “other groups of chil dren.” The authors and two dental assistants then obtained a baseline plaque score using the Sim plified Oral Debris Index (DI-S) compo 592 ■ JADA, Vol. 109, October 1984
nent of the Sim plified Oral Hygiene Index (OHI-S) of Greene and V erm illion,12w hich was m odified to allow for scoring of primary as well as permanent teeth. These scores were ob tained by first applying disclosing solution to the teeth to be studied via a cotton swab, fol lowed by visual examination. After the baseline score was determined, the teachers and aides were instructed on the pro cess of tooth decay, the significance of plaque, and the need for good brushing. They then re ceived individualized instruction in brushing for each child, using any m odification neces sary.13 The teachers and aides were asked to brush the children’s teeth once each day and were told that the dental team w ould check on the progress regularly and be available for help. M uch verbal encouragement and praise was given. W ithin the next 2 months, at different days and times, members of the dental team visited the classrooms to test progress by applying a disclosing solution to the teeth of selected children, offer encouragement, and provide suggestions in im proving toothbrushing. Dur ing this period, each child was tested w ith a disclosing solution three times, as was done for the baseline, and plaque scores were recorded. M uch verbal reinforcement was given and charts were distributed to each classroom to record daily brushing. A t the end of 2 months, the teachers and aides were informed that the study was com pleted and were praised for their efforts. They were encouraged to continue the daily brush ing because of the beneficial effects they were providing. After an additional m onth, during w hich the dental team did not participate in the class rooms, an unscheduled plaque score test was obtained on each child to determine the level of oral hygiene w ithout the constant contact of the dental team and w ith the assumption of the teachers and aides that the study was com pleted.
Results To obtain the Sim plified Oral Debris Index (DI-S), the debris (plaque) scores for the in d i vidual tooth surfaces were totaled and divided by the number of surfaces scored.12 The DI-S
obtained as a baseline was then compared w ith those obtained at subsequent disclosing ses sions for each child during the course of the s tu d y by two-way a n aly sis o f variance (ANOVA) w ith repeated measures.14 Comparisons between the mean scores for each disclosing session showed a significant decrease in the DI-S, F (1,22) = 99.99, P < .001, after the toothbrushing program was in effect w ith m otivational involvem ent by the dental staff. This significant decrease (P < .001) in the DI-S also held when the unscheduled plaque score was taken 1 m onth later. There were no significant differences between the last score obtained during m otivational involvem ent and the unscheduled score taken 1 month later. No statistical differences were found (Table 1) between classrooms, nor when the DI-S of younger children were compared w ith those of the older children (Table 2).
Discussion The significant decrease in the DI-S seen after the toothbrushing program began in the classrooms shows that the classroom teachers and aides were effective in im proving the oral hygiene in this group of multihandicapped children. This change was seen as significant under motiva tional conditions and after these variables were removed. As a source of motivation, the dental team attempted to be visible and provide positive reinforcement to the school staff whenever appropriate. Albertson and Johnsonls stressed the importance of con tinuous evaluation and reinforcement in the design of a plaque control program for institutionalized children. Verbal rein forcement for the attendants was deemed important. To further motivate the school staff, they were told that they (and their stu dents) would be participants in a study in which “other children” would also be in volved. F ull and others6 discuss the Hawthorne effect in- which participants consciously influence the study because
Table 1 ■ Mean pretest, posttest, and unscheduled plaque scores (DI-S), according to classroom. Classroom A B C D E Total
N
Pretest
Posttest
Unscheduled
5 7 4 5
1.802 2.164 2.333 2.466 2.275 11.040
0.80* 1.213* 0.80* 2.434* 1 .00 * 5.247*
0.834* 1.309* 0.730* 1 .20 * 0.970* 5.043*
6
*P < .001.
Table 2 ■ Mean pretest, posttest, and unscheduled plaque scores (DI-S), according to chronologic age. Chronologic age (yr)
Young Old Total *p < .001.
2.5-5 6-18
N
Pretest
Posttest
Unscheduled
16
2.093 2.362 4.455
0.981* 1.197* 2.178*
1.016* 1.075* 2.091*
11
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they know they are being measured. It was hoped that the desire to have positive results for their classroom would influ ence the staff. After the classroom teachers and aides were informed that the study was completed and contact with the dental team ended for 1 month, the changes in the DI-S were maintained. It appears then that once the program was incorporated into the daily routine, it did not require constant input from the dental team. In fact, daily classroom brushing was written into the children’s educa tional plans (IEPs) by the teachers during the course of the study. Whether this im plies that these teachers and aides will ’ continue to maintain the DI-S at the same level rather than allow the scores to re gress over time is still unanswered. Follow-up plaque scores after longer intervals would resolve this question. A comparison was made between the d iffe re n t classroom s to determ ine ■ whether toothbrushing ability or motiva tion varied among the teachers/aides. No statistical differences were found. Younger children were also compared with the older children to test whether the age of the child influenced the level of oral hygiene or the ability of the teachers and aides to brush the teeth. Preschool children (aged 2xk to 5 years) were com pared with school-age children (aged 6 to 18 years) and no differences were found between the two groups, indicating that age or dentitional stage are not significant factors. This would seem to agree with the findings of Powell,3who reported that the level of oral hygiene improved with IQ and was not related to chronologic age. As the subjects in this study were all pro fo un d ly m u ltip ly im paired, they all la c k e d m an y self-help s k ills a n d chronologic age seemed to influence only the size and strength of the child. Indeed, the dental team observed that the younger
children tended to be docile and allowed toothbrushing, compared with many of the older children who struggled during toothbrushing. It was noted, but not tested, that when plaque scores were taken later, there was less resistance from the older children. This may help explain the lack of difference in plaque scores be tween the two age groups, but it is only an observation that these older children ap peared to become more tolerant of tooth brushing. Because this group of children was not anticipated to have a high level of cooper ation nor significant levels of calculus, an effort was made to make disclosing ses sions as brief and nontraumatic as possi ble. A decision was made to only use the DI-S portion of the Sim plified OralHygiene Index.12 During disclosing, a tendency to find more plaque on posterior rather than anterior tooth surfaces and also on lingual more than facial surfaces was observed but not tested. This may re late to the accessibility of these surfaces, but did not relate to age of the child. It would appear, then, that the class room teachers and aides for children who are multihandicapped are able to improve the level of oral hygiene in these children w ith a classroom brushing program under both motivational and nonmotivational situations.
___________________________ JABA
The informed consent of the parents of the children and classroom teachers who participated in the ex perimental investigation reported or described in this manuscript was obtained after the nature of the pro cedure and possible discomforts and risks had been fully explained. The conduct of this study was ap proved by the Institutional Review Board for the Pro tection of Human Subjects of the University of Neb raska Medical Center (IRB no. 20-82). This study was supported in part by the Meyer Childrens’ Rehabilitation Institute of the University of Nebraska Medical Center.
REPORTS
The authors thank Patricia A. Galvan-Ariza, CDA, and Marchelle R. Wilwerding, CDA, for their clinical assistance. Dr. U din is instructor, department of pediatrics, College of Medicine, and Dr. Kuster is associate pro fessor, department of pedodontics, College of Den tistry, University of Nebraska Medical Center, 42nd and Dewey Ave, Omaha, 68105. Address requests for reprints to Dr. Udin. 1. Nowak, A.J. Dentistry for the handicapped pa tient. St. Louis, C. V. Mosby Co, 1976. 2. Svatun, B., and Gjermo, P. Oral hygiene, peri odontal health and need for periodontal treatment among institutionalized mentally subnormal persons in Norway. Acta Odontol Scand 36(2):89-95, 1978. 3. Powell, E.A. A quantitative assessment of the oral hygiene of mentally retarded residents in a state institution. J Public Health Dent 33(l):27-34,1973. 4. Peterson, D.S., and others. The use of vanity to improve oral hygiene behavior in the retarded. J Mich Dent Assoc 60:463-466, 1978. 5. Kass, L. Dental health program for the institu tionally mentally retarded. Dent Hygiene 53:76-78, 1979. 6. Full, C.A., and others. Oral health maintenance of the institutionalized handicapped child. JADA 94(1):111-113, 1977. 7. Goyings, E.D., andRiekse, D.M. The periodontal condition of institutionalized children; improvement through oral hygiene. J Public Health Dent 28(1):5-15, 1968. 8. Price, J.H. Dental health education for the men tally and physically handicapped. J School Health 48(3):171-174, 1978. 9. Leary, B.A., and Zucker, S.B. Teaching preven tive dentistry to adolescents with cerebral palsy. Spec Care Dent 1(1):13-17,1981. 10. Schwartz, B.H., and others. Development and evaluation of a dental health training program for se verely retarded children. J Dent Handicap 4(l):17-22, 1978. 11. Albino, J.E., and others. Results of an oral hygiene program for severely retarded children. J Dent Child 46(l):25-28,1979. 12. Greene, J.C ., and V e r m illio n , J.R. The simplified oral hygiene index. JADA 68(1):26-31, 1964. 13. Johnson, R., and Albertson, D. Plaque control for handicapped children. JADA 84(4):824-828,1972. 14. Myers, J. Fundamentals of experimental de sign, ed 3. Boston, A llyn and Bacon, Inc, 1979. 15. Albertson, D., and Johnson, R. Plaque control for the institutionalized child. JADA 8 7(6): 13891394, 1973.
Should dentists advise smokers to stop? Kristi J. Ferguson, PhD Henrietta L. Logan, PhD Paul R. Pomrehn, M D
D ecent evidence suggests that health care providers’ efforts to counsel their pa tients to stop smoking can significantly
decrease smoking-related morbidity and mortality.1'3 In a large-scale study of physician advice-giving, Russell and col leagues4 concluded that even if practitio ners achieved only a 5% success rate, public health would improve signifi cantly if practitioners advised all smokers
to stop. They argue that such advice in creases the number of attempts to stop, even if it does not increase the success rate of those who attempt to stop smok ing. Their study also found that twothirds of patients (67%) express interest in trying to stop.
Ferguson-Logan-Pomrehn : DENTISTS’ ADVICE TO SMOKERS ■ 593
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reference SLS diet. The difference be tween the cariogenicity of these products and the other snack foods could be attrib uted to the additional cariostatic ingre dients (milk, peanuts, or cocoa, or all three), in addition to alterations in the other physical parameters of foods, as previously mentioned.
Summary The use of the animal model and the Konig-Hofer program-feeding machine is a valuable tool in the research effort to identify the factors contributing to dental caries. As this methodology provides uniform host, microflora, and frequency components, the food is the variable being evaluated. The relative cariogenicity of food is de pendent on variations in the composition, texture, solubility, retentiveness, and ability to stimulate saliva flow. The re sults of these experiments indicated the equal importance of all food-related pa rameters on dental caries formation. If the composition of foods was solely respon sible for dental caries formation, all three of the granola bars should have had simi lar relative cariogenicity values. This was not true. Granola bar no. 3, which was crispier in texture and less moist, had a third the relative cariogenicity value of granola bars nos. 1 and 2. As reported by other d e n ta l re searchers, the production of dental caries
is food related, but not simplistic in na ture. Dental caries is the outcome of com plicated interactions, all of which are equally important in the progress of this ________________________ J'A O A diseaseThis study was done by Hershey Foods Corp. The authors thank Donna M. Boltz and Deborah K. Keiper for their technical assistance. Mr. Morrissey is senior scientist; Mr. Burkholder is a scientist, nutrition research; and Dr. Tarka is direc tor, Life Sciences Research, Hershey Foods Corp, Technical Center, 1025 Reese Ave, Box 805, Hershey, PA 17033-0805. Address requests for reprints to Dr. Tarka. 1. Alfano, M.C. Dental caries: the nature of the problem. Cereal Foods World 26(l):5-9, 1981. 2. Newbrun, E. Sugar and dental caries. Clin Pre vent Dent 4(3):11-14, 1982. 3. Bowen, W.H., and others. A method to assess cariogenic potential of foodstuffs. JADA 107(4):677681, 1980. 4. vanHoute, J., and others. Role of sucrose in col onization of Streptococcus mutans in conventional Sprague-Dawley rats. J Dent Res 55(2):202-215,1976. 5. Fitzgerald, R.J., and Fitzgerald, D.B. The micro biological status of test animals in relation to caries research. In Tanzer, J.M., ed. Proceedings, sym posium on animal models in cariology. Microbiol Abstr (Special Suppl), 1981, pp 89-95. 6. Navia, J.M. Evaluation of nutritional and dietary factors that m odify an im a l caries. J Dent Res 49(6):1213-1227, 1970. 7. Navia, J.M., and Lopez, H. Rat caries assay of reference foods and sugar containing snacks. J Dent Res 62(8):893-898, 1983. 8. Keyes, P.H. Dental caries in the molar teeth of rats. A method for diagnosing and scoring several types of lesions simultaneously. J Dent Res 37:10881099, 1958.
REPORTS
9. Larson, R.H. Merits and modifications of scoring rat dental caries by Keyes method. In Tanzer, J.M., ed. Proceedings, symposium on anim al models in cariol ogy. Microbiol Abstr (Special Suppl), 1981, pp 195203. 10. Schalm, O.W.; Jain, N.C.; and Carroll, E.J. Vet erinary hematology, ed 3. P h ila d e lp h ia , Lea & Febiger, 1974, pp 239-240. 11. Guzzenheim, B.; Schmid, R.; and Muhlemann, H.R. Programmed feeding. In Tanzer, J.M., ed. Pro ceedings, symposium on animal models in cariology. Microbiol Abstr (Special Suppl), 1981, pp 391-401. 12. Gustafsson, B.E., and others. The Vipeholm dental caries study. The effect of different levels of carbohydrate intake on caries activity in 436 indi viduals observed for five years. Acta Odontol Scand 11:232-364, 1954. 13. Stralfors, A. Inhibition of hamster caries by cocoa. The effect of whole and defatted cocoa, and the absence of activity in cocoa fat. Arch Oral Biol 11:149-161, 1966. 14. Stephan, R.M. Effects of different types of hum an foods on dental health in experimental ani mals. J Dent Res 45(5):1551-1561, 1966. 15. Jenkins, G.N. Enamel protective factors in food. J Dent Res 49(6):1318-1325, 1970. 16. Sreebny, L.M. Cariogenicity of cereal grains. C om m unity Dent Oral Epidem iol 11(3):148-155, 1983. 17. Caldwell, R.C. Physical properties of foods and th e ir caries-producing p o te n tia l. J D ent Res 49(6):1293-1299, 1970. 18. Nizel, A.E. Dental caries: protein, fats, and car bohydrates. NY State Dent J 35:71-81, 1969. 19. Mandel, I.D. Diet and dental decay. Nutr Health 2(3):l-6, 1980. 20. DePaola, D.P., and Alfano, M.C. Diet and oral health. Nutr Today 12(3):6-11; 29-32, 1977. 21. Adams, C.F. N utritive value of American foods— in common units. Agriculture handbook no. 456. Washington, DC, US Department of Agriculture, 1975. 22. Weiss, M.E., and Bibby, B.G. Some protein ef fects on enamel solubility. Arch Oral Biol 11:59-63, 1966.
The influence of motivation on a plaque control program for handicapped children Richard D. Udin, DDS Curtis G. Kuster, DDS, M S
i >' iscussions about the dental needs of the handicapped population have ap peared frequently in the dental literature and were reviewed by Nowak.1 In iden tifying these needs, studies have focused on the problems of the patient who lives in an institution. Svatun and Gjermo2 studied such a population (aged 5 to 45) in Norway and found that the oral hygiene and periodontal health were generally poor. Powell,3 in studying an
institutionalized sample, found that the level of oral hygiene was related to the degree of mental retardation. These studies point to the need for pre ventive programs geared for this popula tio n . These p ro g ra m s , w h e n im plemented for patients who are living in institutions, have generally taken one of two forms. The first involves training the patients to care for their own teeth and the second involves the training and motiva tion of the attendants to provide this care. The former was studied by Peterson and others.4 The authors appealed to the van ity of 15 trainable, mentally handicapped males to gain im provem ent in oral hygiene scores. Kass5 had attendants teach and motivate m entally h a n d i capped young adults in proper oral
hygiene techniques, which led to an im provement of hygiene level. By making the attendants responsible for the patients’ plaque removal, Full and others6 were able to demonstrate effec tiveness. In a study by Goyings and Riekse,7 the investigators were able to im prove pe rio do n tal c o n d itio n s by brushing the patients’ teeth twice a day. Many of the mentally and physically h an d icap pe d p o p u la tio n have been moved out of institutions and into com munities in which group and nursing homes, vocationally oriented residences, or families have taken over the care. As a part of this norm alization and dein stitutionalization process, Public Law 94-142 (the Education for A ll H andi capped Children Act of 1975, 20 USC
Udin-Kuster : PLAQUE CONTROL PROGRAM FOR HANDICAPPED CHILDREN ■ 591
BRIEF
REPORTS
1401) was passed, which ensures that each handicapped child receives educa tional services from school age to age 21. These services may be provided by the public school system or contracted to pri vate, government-supported facilities. Also, dental care and prevention, instead of being provided within the institution, are now provided within the community. The special education teachers, who are charged with the training and care of these children, are in a position in which oral hygiene maintenance could be in corporated into the daily classroom routine. In many instances, this has not occurred. Price8 asserts that any dental health education program for people with handicaps should start with inservice education for the classroom teachers. In deed, these individuals are in an excel lent position to instruct the handicapped child in proper oral health maintenance or to provide this care. Yet, according to Leary and Zucker,9 special education teachers an d therapists are seldom trained to administer oral hygiene in struction. These authors showed that dental students were able to teach adoles cents who have cerebral palsy to brush at a special education center. Also, in studies by Schwartz and others10and A l bino and others,11 dental personnel were able to teach severely handicapped chil dren to brush their teeth in the classroom. The purpose of this study was to deter mine whether special education teachers and aides/technicians could improve the oral hygiene of a group of profoundly handicapped children after the children received training in techniques and whether this improvement could be af fected by motivation.
Methods Thirty profoundly, m u ltiply im paired pre school and school-age children were in itially selected to participate in this study. AH sub jects were enrolled in the Multi-handicapped Childrens’ Program at the Hattie B. Monroe Pavilion of the Meyer Childrens’ Rehabilita tion Institute. This program provides an educa tional environment for the children and also serves to train professionals from various dis ciplines. Three subjects were elim inated from the study because of significant absences from school. The participants ranged in age from 3 to 17 years w ith cognitive abilities ranging from birth to 3 years. M any children also had severe sensory and motor disabilities w ith few self-help skills. There were 19 males and 8 females. In the in itia l phase of the study, the authors inform ed the classroom teachers and aides that the children in their class w ould be involved in a study to test the effectiveness of toothbrushing by the teachers in reducing the plaque in the children’s mouths, and that these children w ould participate w ith “other groups of chil dren.” The authors and two dental assistants then obtained a baseline plaque score using the Sim plified Oral Debris Index (DI-S) compo 592 ■ JADA, Vol. 109, October 1984
nent of the Sim plified Oral Hygiene Index (OHI-S) of Greene and V erm illion,12w hich was m odified to allow for scoring of primary as well as permanent teeth. These scores were ob tained by first applying disclosing solution to the teeth to be studied via a cotton swab, fol lowed by visual examination. After the baseline score was determined, the teachers and aides were instructed on the pro cess of tooth decay, the significance of plaque, and the need for good brushing. They then re ceived individualized instruction in brushing for each child, using any m odification neces sary.13 The teachers and aides were asked to brush the children’s teeth once each day and were told that the dental team w ould check on the progress regularly and be available for help. M uch verbal encouragement and praise was given. W ithin the next 2 months, at different days and times, members of the dental team visited the classrooms to test progress by applying a disclosing solution to the teeth of selected children, offer encouragement, and provide suggestions in im proving toothbrushing. Dur ing this period, each child was tested w ith a disclosing solution three times, as was done for the baseline, and plaque scores were recorded. M uch verbal reinforcement was given and charts were distributed to each classroom to record daily brushing. A t the end of 2 months, the teachers and aides were informed that the study was com pleted and were praised for their efforts. They were encouraged to continue the daily brush ing because of the beneficial effects they were providing. After an additional m onth, during w hich the dental team did not participate in the class rooms, an unscheduled plaque score test was obtained on each child to determine the level of oral hygiene w ithout the constant contact of the dental team and w ith the assumption of the teachers and aides that the study was com pleted.
Results To obtain the Sim plified Oral Debris Index (DI-S), the debris (plaque) scores for the in d i vidual tooth surfaces were totaled and divided by the number of surfaces scored.12 The DI-S
obtained as a baseline was then compared w ith those obtained at subsequent disclosing ses sions for each child during the course of the s tu d y by two-way a n aly sis o f variance (ANOVA) w ith repeated measures.14 Comparisons between the mean scores for each disclosing session showed a significant decrease in the DI-S, F (1,22) = 99.99, P < .001, after the toothbrushing program was in effect w ith m otivational involvem ent by the dental staff. This significant decrease (P < .001) in the DI-S also held when the unscheduled plaque score was taken 1 m onth later. There were no significant differences between the last score obtained during m otivational involvem ent and the unscheduled score taken 1 month later. No statistical differences were found (Table 1) between classrooms, nor when the DI-S of younger children were compared w ith those of the older children (Table 2).
Discussion The significant decrease in the DI-S seen after the toothbrushing program began in the classrooms shows that the classroom teachers and aides were effective in im proving the oral hygiene in this group of multihandicapped children. This change was seen as significant under motiva tional conditions and after these variables were removed. As a source of motivation, the dental team attempted to be visible and provide positive reinforcement to the school staff whenever appropriate. Albertson and Johnsonls stressed the importance of con tinuous evaluation and reinforcement in the design of a plaque control program for institutionalized children. Verbal rein forcement for the attendants was deemed important. To further motivate the school staff, they were told that they (and their stu dents) would be participants in a study in which “other children” would also be in volved. F ull and others6 discuss the Hawthorne effect in- which participants consciously influence the study because
Table 1 ■ Mean pretest, posttest, and unscheduled plaque scores (DI-S), according to classroom. Classroom A B C D E Total
N
Pretest
Posttest
Unscheduled
5 7 4 5
1.802 2.164 2.333 2.466 2.275 11.040
0.80* 1.213* 0.80* 2.434* 1 .00 * 5.247*
0.834* 1.309* 0.730* 1 .20 * 0.970* 5.043*
6
*P < .001.
Table 2 ■ Mean pretest, posttest, and unscheduled plaque scores (DI-S), according to chronologic age. Chronologic age (yr)
Young Old Total *p < .001.
2.5-5 6-18
N
Pretest
Posttest
Unscheduled
16
2.093 2.362 4.455
0.981* 1.197* 2.178*
1.016* 1.075* 2.091*
11
B R IE F
they know they are being measured. It was hoped that the desire to have positive results for their classroom would influ ence the staff. After the classroom teachers and aides were informed that the study was completed and contact with the dental team ended for 1 month, the changes in the DI-S were maintained. It appears then that once the program was incorporated into the daily routine, it did not require constant input from the dental team. In fact, daily classroom brushing was written into the children’s educa tional plans (IEPs) by the teachers during the course of the study. Whether this im plies that these teachers and aides will ’ continue to maintain the DI-S at the same level rather than allow the scores to re gress over time is still unanswered. Follow-up plaque scores after longer intervals would resolve this question. A comparison was made between the d iffe re n t classroom s to determ ine ■ whether toothbrushing ability or motiva tion varied among the teachers/aides. No statistical differences were found. Younger children were also compared with the older children to test whether the age of the child influenced the level of oral hygiene or the ability of the teachers and aides to brush the teeth. Preschool children (aged 2xk to 5 years) were com pared with school-age children (aged 6 to 18 years) and no differences were found between the two groups, indicating that age or dentitional stage are not significant factors. This would seem to agree with the findings of Powell,3who reported that the level of oral hygiene improved with IQ and was not related to chronologic age. As the subjects in this study were all pro fo un d ly m u ltip ly im paired, they all la c k e d m an y self-help s k ills a n d chronologic age seemed to influence only the size and strength of the child. Indeed, the dental team observed that the younger
children tended to be docile and allowed toothbrushing, compared with many of the older children who struggled during toothbrushing. It was noted, but not tested, that when plaque scores were taken later, there was less resistance from the older children. This may help explain the lack of difference in plaque scores be tween the two age groups, but it is only an observation that these older children ap peared to become more tolerant of tooth brushing. Because this group of children was not anticipated to have a high level of cooper ation nor significant levels of calculus, an effort was made to make disclosing ses sions as brief and nontraumatic as possi ble. A decision was made to only use the DI-S portion of the Sim plified OralHygiene Index.12 During disclosing, a tendency to find more plaque on posterior rather than anterior tooth surfaces and also on lingual more than facial surfaces was observed but not tested. This may re late to the accessibility of these surfaces, but did not relate to age of the child. It would appear, then, that the class room teachers and aides for children who are multihandicapped are able to improve the level of oral hygiene in these children w ith a classroom brushing program under both motivational and nonmotivational situations.
___________________________ JABA
The informed consent of the parents of the children and classroom teachers who participated in the ex perimental investigation reported or described in this manuscript was obtained after the nature of the pro cedure and possible discomforts and risks had been fully explained. The conduct of this study was ap proved by the Institutional Review Board for the Pro tection of Human Subjects of the University of Neb raska Medical Center (IRB no. 20-82). This study was supported in part by the Meyer Childrens’ Rehabilitation Institute of the University of Nebraska Medical Center.
REPORTS
The authors thank Patricia A. Galvan-Ariza, CDA, and Marchelle R. Wilwerding, CDA, for their clinical assistance. Dr. U din is instructor, department of pediatrics, College of Medicine, and Dr. Kuster is associate pro fessor, department of pedodontics, College of Den tistry, University of Nebraska Medical Center, 42nd and Dewey Ave, Omaha, 68105. Address requests for reprints to Dr. Udin. 1. Nowak, A.J. Dentistry for the handicapped pa tient. St. Louis, C. V. Mosby Co, 1976. 2. Svatun, B., and Gjermo, P. Oral hygiene, peri odontal health and need for periodontal treatment among institutionalized mentally subnormal persons in Norway. Acta Odontol Scand 36(2):89-95, 1978. 3. Powell, E.A. A quantitative assessment of the oral hygiene of mentally retarded residents in a state institution. J Public Health Dent 33(l):27-34,1973. 4. Peterson, D.S., and others. The use of vanity to improve oral hygiene behavior in the retarded. J Mich Dent Assoc 60:463-466, 1978. 5. Kass, L. Dental health program for the institu tionally mentally retarded. Dent Hygiene 53:76-78, 1979. 6. Full, C.A., and others. Oral health maintenance of the institutionalized handicapped child. JADA 94(1):111-113, 1977. 7. Goyings, E.D., andRiekse, D.M. The periodontal condition of institutionalized children; improvement through oral hygiene. J Public Health Dent 28(1):5-15, 1968. 8. Price, J.H. Dental health education for the men tally and physically handicapped. J School Health 48(3):171-174, 1978. 9. Leary, B.A., and Zucker, S.B. Teaching preven tive dentistry to adolescents with cerebral palsy. Spec Care Dent 1(1):13-17,1981. 10. Schwartz, B.H., and others. Development and evaluation of a dental health training program for se verely retarded children. J Dent Handicap 4(l):17-22, 1978. 11. Albino, J.E., and others. Results of an oral hygiene program for severely retarded children. J Dent Child 46(l):25-28,1979. 12. Greene, J.C ., and V e r m illio n , J.R. The simplified oral hygiene index. JADA 68(1):26-31, 1964. 13. Johnson, R., and Albertson, D. Plaque control for handicapped children. JADA 84(4):824-828,1972. 14. Myers, J. Fundamentals of experimental de sign, ed 3. Boston, A llyn and Bacon, Inc, 1979. 15. Albertson, D., and Johnson, R. Plaque control for the institutionalized child. JADA 8 7(6): 13891394, 1973.
Should dentists advise smokers to stop? Kristi J. Ferguson, PhD Henrietta L. Logan, PhD Paul R. Pomrehn, M D
D ecent evidence suggests that health care providers’ efforts to counsel their pa tients to stop smoking can significantly
decrease smoking-related morbidity and mortality.1'3 In a large-scale study of physician advice-giving, Russell and col leagues4 concluded that even if practitio ners achieved only a 5% success rate, public health would improve signifi cantly if practitioners advised all smokers
to stop. They argue that such advice in creases the number of attempts to stop, even if it does not increase the success rate of those who attempt to stop smok ing. Their study also found that twothirds of patients (67%) express interest in trying to stop.
Ferguson-Logan-Pomrehn : DENTISTS’ ADVICE TO SMOKERS ■ 593