Preventive Measures

Effect of regular small group instructionper se on oral health statusof Danish schoolchildren

N, AGERB/EK*, B , MELSF.N-"", O . P , LINIVI", L, CLAN'IND* AND B, KRISTIANSEN^'

'"^Institute oj Periodontotogy, '•"'Institute oj Orthodontics, Mnstittitc oj Dental Public Health,Royal Dental College, Aarhus attd 'f^Childrcn's Oral Health Care Services, Silkcborg,Denmark

Agerba'k, N,, Melsen, B,, Lind, O. P,, Glavind, L. & Kristiansen, B.: Effect of regular smallgrouj) itistiuction jjer se on oral health status of Danish sehoolchildreii. Community Dent.Oral I':pidemiol, 1979: 7: 17-20,

Abstract - A l-\ear study of the isolated effect of an intensive moti\'ation program aimedal improving the oral health stattts of 11-13-year-old schoolchildren was conducted in aDanish i^rovincial to%vn where- all children have access lo a free and comprehensive sehooloral health program. The effeet was negligible as measured by e]Mdemioiogic indices,

|uc; gingivitis: health education, dental; oral healthKey words: dental caries; dentalstatus.

Nina Agerba>k, Institute of Periodontology, Royal Dental College, Vennelyst Boulevard,DK-8000 Aarhus, Denmark

Accepted for pui)liealion 15 October 1978

Combined preventive programs consisting of fre-quent professional removal of soft and hard depo,s-its on the surfaces of the teeth, the regular useof an anti-caries agent and the activation of thepatietit towards regular and effecti\'e iiersonal oralhygiene have been found to be very promising inthe combat against both dental caries and gingivitis.In a reeent revie\v on preventive programs forchildren and teenagers (1 ) it was stated that .sys-tematic itiforniation on etiology and tbe possibilityof self control of caries and gingiviti,s/periodontitisare likely to contribute to the good eooperationand the remarkably good restilts loiind in the Karl-,stad study (2), Furthermore, it was recommendedto include systematic information on oral healthand the motivation for preventive measures bothcollectively and individuall)' in specific pre\'emiveprograms for the various age grotips of ehildren.In most oral liealth care districts of Scandinaviastandard dental health education programs arc-

generally accepted, and the programs are adaptedto the local needs of the children.

Realizing this, the purpose of the present studywas to evaluate the effect of a dental healthprogram which seemed lo be a considerable un-provement on the existing standard program andwhich Nvas acceptable to dentist, dental auxiliaries,the children and the ,sc;hool authorities. The studyalso intended to provide a basis for discussions ontbe future role of modem dental health educationas part of the pre\ entive programs of the oral healtheare delivery system iti Detnnark,

MATERIAL AND METHODSIn a ]3rovincial loxsn with a negligible amount of fluoridein the drinking water (<0 .1 part/10'T) eight school classeswith a total of 193 children, 11-13 years of age, wereselected for the study.

The vast majority of the schoolchildren have participatedon a tegular basis in the municipal childrens' oral liealth

0301-5661/79/010017-04 $02.50/0 © 1979 Munksgaard, Copenhagen

18 AGERB/EK, MELSEN, LIND, GLAVIND AND KULSTIANSEN

Table 1, Baseline data and average increment in cariesand fillings afler 12 months {X ± s.e,)

I est group Control

DMFS ba.seline 8.70±2.07 8.66±2,46 > 0,05

DMFS increment 1.77±O,34 2,21 ±0,43 > 0,05

Caries incrementon smooth surfaces 0.48±0.28 l,19±0.32 > 0.05

New filledsurfaces 3.89±0,35 3.48±0.38 > 0.05

New filled surfaces-dentist's data 4.07±0.,54 3,79 ±0,36 > 0,05

service iro!7i lhe 1st grade. Though the schoolchildren andtheir parents have been exposed to some information andinstruction related to oral health, these activities havenever been organized into a dental health education pro-gram.

Before the initiation of this program and 1 year later thechildren were examined clinically. Dental plaque and gin-givitis were recorded by one of the authors (N, A,) usingthe criteria and indices described by SILNUSS & Loi: (6)and LoE & Sii.Ni.ss (4), Caries, including incipient lesions,was recorded by another of the authors (B, M,) assjjecified by MIILLKR & POUL.SI.N (5), Teeth with ortho-dontic bands and teeth extracted for orthodontic reasonswere excluded from both sets of data.

The children were then allocated into test and controlgroujjs. Two 5th grade classes and two 6th grade classeswere randomly a,ssigned to the test and control groupsrespectively, ll was cnsiired ihat llie test and control groupswere balanced with regard to sex and socioeeonomic status.Furthermore, data on smooth surface carious lesions fromthe baseline examination showed a similar dental cariessituation for test and control groups (Table 1), Both test,and control groups received the normal preventive pro-gram of the school denial service compiisitig classroominstruction in toothbrushing twice a year, and a fortnightlymouthrinsing with 0,2 % sodium fluoride solution duringschool months. Toothpaste was sup|5lied free of charge loall the children throughout the year of study. The ex-perimental dental health education program was, therefore,a supplement to the services already provided by the scliooldental service.

The experimental dental health education ])rogram wasadministrated by a dental hygienist (B, K,), At the begin-ning of the program the parents of the test group receivedwritten information on the dental health education pro-gram emphasizing the importance of continuous parental,siipport. The letter also contained information on theetiology and prevention of the common oral diseases, Si-nuiltaneously, the teachers agreed to integrate dental healthmaterial iu biology and Danish classes. The backbone of

the program wa.s an organized series of fortnightly 20-minsmall gronp sessions with 8-10 test groitp children each,conducted by the dental hygienist.

The initial sessions were focused on personal oral hygienpincluding detailed instruction in toothbnishing. DentaJ])lac[ue was demonslrated using disclosing tablets and tbechildren evaluated the plaque situation of the group.Through sujjei-vised toothbrushing the plaque removal ef,feet of the brushing was evaluated. The etiology of denialcaries was explained to the children using various tech-,jiiqites. The enamel decalcifying effect of even weak acid^was shown on extracted teeth. Drawings, models and serit'Sjof color slides were used to illustrate the role of micro,organisms and the stages of carious tooth destruction, TKi.role of diet and especially the detrimental effect of cario^gcnic carbohydrates were exjjlained and demonstrated tqthe children by the dental hygienist. and later reinforcec^by tbe teacher of domestic science. The possibility of svib,stituting sucrose in .sweets and soft drinks was discussec)and diffei-cnt types of sugarfree sweets and soft drinks we ^provided for the children. The role of fluoride in the;prevention of dental caries was exijlained and discussed^Later the problems of dental plaque were highlighted bymeans of a check-up on each child and the production ofdiagrams di,splayiiig ])laque localization. The children cul,tivated tlieir own bacterial ]jlaque on agar plates anc^studied the microorganisms under a microscope. Reinslruc^tion in toothbrushing was given aecording to the individualneeds. Gradually the more sophisticated methods of me,ehanical jjlaqne removal including dental flossing wertiintroduced and practiced.

In cooperation with the teacher of biology efforts wer(^made to attain a high degree of reinforcement throughformal lessons and free discussions in the classroom. Den,tal health education jjostcrs were produced during CreativeArt c!a,sses to encourage active involvement.

In order to evaluate the effect of the program oi^knowledge and attitudes of the children towards preven,tion of dental disease, a multiple choice test, comprising12 questions was given after 1 year to both test and con,trol children. Furthermore, the teachers let their student,^write a short essay on the significance for their own oralhealth of participation in the program, I'he essays wer ^read by one of the investigators (L.G,) and scanned forcomments or statements related to changes in oral hygieneand eating liabit.s, significance of participation in the pro,gram, and feelings or atiiuides towards participation in lh<.>program.

Finally, at the end of the study period the test groupchildren were given the choice of conlinuing or ceasing to))ar(ici))ate in a similar program the following year. At theend of the 1st year of the ])rogram the recordings wereperformed without the examiners knowing to whicli groupthe chiidieii were allotted.

RESULTS

Table 1 shows baseline dala and the average cariesincrements for permanent teeth of test and control

Effect of instruction on oral liealth 19

Table 2, Mean and frequency distribution ol placjue and giiigi\al index of experimental aud control group at baselineand after I year

Test1976

Control1976

Test1977

Control1977

n

88

89

84

86

Plac|iieindex

X

1,16

1,36

0,90

0,97

Plaque

Frec|ueneyscore 0

% s.e.

29,1 4.86

19.8 5.01

40.8 5.36

36.0 5,18

Frequeneyscore 2-3

% s.e.

33.0 5.01

41,2 5.21

17,2 4.11

20,0 4,31

Gingi\ alindex

.V

1,42

1,53

1.43

1,33

Gingivitis

Frequencyseore 0

% s,e.

15,9 3,89

11,6 3,39

17,1 4.11

18,1 4.16

Frequencyscore 2—3

% s.e.

41,6 5.25

45,2 5,32

37.5 5.28

30,0 4,93

children after 1 year of study. The modest differ-ences between test and control grotips were not sta-tistically significant at the 5 % level. Apparentlysmooth surface caries had been reduced for the testgroup to some degree. The dentist data on newfillings were slightly higher than those obtainedthrough the caries registration sinee relilled surfaeescould not bi; recorded.

Minor improvements in plaque index and gin-gival index seem to have occurred in both grotips,and slightly more in the control than in the testgroup (Table 2), However, differences were notsigtiifieant.

The level of knowledge on oral health as judgedfrom the multiple choice questionnaire revealedlittle differences between experimental and controlgroups. Only on two questions which dealt withthe significanee of bleeding following toothbrushhigand when to renew otie's toothbrush did the testgroup children show a significantly higher level ofknowledge than the control children. However, theanaly,sis of the essays written by the test groupchildren at the end of the study period revealedthat they had apparently become aware of the oralhealth care problems and indicated a positive at-titude towards improving oral habits. Consistentwith this, all the test group children wanted to con-tinue the program the following year,

DISCUSSIONThe health education activities in the present sitidywere of the small grotip elassroom instruction type

supported by minor experiments and reinforced bycoordinated teaching in biology and creati\'e art.Different teaching methodologies were used, butdue to lhe short 20-min sessions the one-way com-munication type was predominant. The methodswere designed in accordance with what is presum-ably a widely accepted program in Denmark, De-spite the great efforts invested, the epidemiologieindices did not indicate any beneficial effect on theoral health status of the test group children frotnthe experimental "treatment".

The target group consisted of 11-13-year-oldsehoolehildren who had participated for at least4 years in a comprehensive ,school oral health caresystem. This regular contact, twice a year, supportedby fortnightly fluoride mouthrinses may have ledto a rather high level of awareness, knowledge, andattittides. On the other hand, the epidemiologicdata show that there is a wide gap between facts(the data) and fancy (the e,ssays). The essays re-vealed a clear understanding of the importance ofpreventing oral diseases and, together \vith thechildren's interest in contintiing the progratn an-other year, a positive attitude to\vards partieipationin the dental health program.

The dental health behavior of the children se-lected for this study may have reached a levelwhere further improvements wotild demand a rath-er sophisticated health education approach. Thelevel of oral health knowledge of the "consumers"has probably been underestimated. In such casesdental health edueation programs may be carriedto exeess, even leading to some sort of "immuniza-

20 AGKRB/KK, MICI.,SEN, LIND, GJ.AVIND ANI) KRI.STIANSEN

tion". Therefore, the findings of the actual studyemphasiy.e the importance of prior assessment of thetarget group and the formulation of a comprehen-sive education diagnosis.

From an educational point of view it could beargued that the degree of active involvement anddecision-making by the children and their familiesduring the 1-year period was too weak and super-ficial.

The findings demonstrated that a 1-year tradi-tional health education program isolated from otherpreventive measures, executed among 11-13-year-old children participating in a free, regular andcomprehensive school dental health .scheme, has noeffect on the oral health status as measured by con-ventional epidemiologic indices. From both a healtheducation point of view and a cost-benefit pointof view such traditional motivational approachesshould be reconsidered in the light of modern socialaud behavioral sciences. On the basis of an educa-tional diagno,si,s the goals and the instructional ob-jectives of the program should be analyzed andformulated. A high degree of consumer involvementto the point where substantial responsibility is dele-gated to the consumers themselves would probablylead to more effective learning and presumably topositive ehanges in the dental health related be-havior (2).

Acknowlcdgtnetils - The authors wish lo thank the Councilof Silkeborg mmiicipalily and the Municipal School Au-(liori(y for the inleresl, cooperation and sup|jor( c:x(endedduring (he; s(udy period, Spec-ial thanks are extended lothe Chief Denial Health Officer, Dr, J, R..vv,\ and hisstaff. We also owe all the ehildren, their jiarents andthe teac:hers our a|)])reciation. The sludy was finaneiallysupported by a grant from The Danish Medieal ResearchCouneil No, 512-7091, and from Ihc- Colgate-PalmoliveEouudaliou,

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