|Year : 2016 | Volume
| Issue : 1 | Page : 43-47
Impact of verbal, braille text, and tactile oral hygiene awareness instructions on oral health status of visually impaired children
P Brahmanna Chowdary, KS Uloopi, C Vinay, V Veerabhadra Rao, Chandrasekhar Rayala
Department of Pedodontics and Preventive Dentistry, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
|Date of Web Publication||2-Feb-2016|
K S Uloopi
Department of Pedodontics and Preventive Dentistry, Vishnu Dental College, Vishnupur, Bhimavaram - 534 202, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Visually impaired children face limitations in interacting with the environment, as they cannot see the facial expression of parents, teachers and cannot perceive social behavior. These children are challenged every day in learning basic life skills and maintenance of oral hygiene being one among them. Aim: To evaluate the impact of verbal, braille text, and tactile oral hygiene awareness instructions on oral health status of visually impaired children. Materials and Methods: One hundred and twenty institutionalized visually impaired children aged 6-16 years were selected and divided into three groups (40 children each). Group I: Verbal and tactile, Group II: Verbal and braille, Group III: Verbal, braille, and tactile. Instructions regarding maintenance of good oral hygiene and brushing technique were explained to all the children, and oral health status of these children using plaque index (Silness and Loe) and gingival index (Loe and Silness) was evaluated at 1, 3, and 6 months interval. Statistical Analysis: ANOVA test was used to analyze the intra- and inter-group comparisons and Tukey post-hoc test for multiple group comparisons. Results: Children in all the groups showed reduction in plaque and gingival scores. There was the highest percentage of reduction in plaque scores in Group III (70.6%), and the decrease in gingival scores was the highest in Group II (84%). Conclusion: Severity of dental plaque and gingivitis in visually impaired individuals can be reduced by a controlled and supervised educational program. The combination of all three, i.e., verbal, braille, and tactile mode of oral health educational aids proved to be effective.
Keywords: Braille text, gingivitis, oral hygiene, plaque, tactile perception, verbal instructions, visually impaired children
|How to cite this article:|
Chowdary P B, Uloopi K S, Vinay C, Rao V V, Rayala C. Impact of verbal, braille text, and tactile oral hygiene awareness instructions on oral health status of visually impaired children. J Indian Soc Pedod Prev Dent 2016;34:43-7
|How to cite this URL:|
Chowdary P B, Uloopi K S, Vinay C, Rao V V, Rayala C. Impact of verbal, braille text, and tactile oral hygiene awareness instructions on oral health status of visually impaired children. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2019 Jul 15];34:43-7. Available from: http://www.jisppd.com/text.asp?2016/34/1/43/175510
| Introduction|| |
Health is a state of complete physical, mental, and social well-being, rather than solely the absence of disease (WHO).  Good health is a fundamental right, a social goal, and essential human need. Oral health is a vital component and an intrinsic part of general health. 
Handicap is a loss or limitation of opportunities to take part in normal life of the community on an equal level with others due to physical or social barriers.  Children who require special care are said to be at higher risk in oral health perspective.  They often face difficulty in good oral hygiene maintenance due to their systemic illness and inaccessibility to dental care. 
Vision is the most important sense for interpreting the environment around us, and when sight is impaired in childhood, it can have detrimental effects on physical, neurological, cognitive and emotional development.  The WHO estimates that there are 40 million blind persons in the world and among them over 15 million are in India.
Visually impaired children lack the ability to maintain good oral health, since they cannot detect and recognize early oral diseases.  Hence, certain interventions are needed to educate these children regarding maintenance of their oral health. Various studies proved that oral hygiene instructions either direct or indirect are beneficial in normal children. ,,, However, literature is scanty regarding the type of oral hygiene instructions that may have a better impact on visually impaired children. Hence, the purpose of this study was to evaluate the impact of verbal instructions, braille text, and tactile demonstration as an educative tool to motivate visually impaired children and to improve their oral health status.
| Materials and Methods|| |
This prospective, interventional study was approved by the Institutional Review Board. Prior written consent was obtained from the school authority and parents by explaining the purpose of the study.
Four residential schools which provide special education for visually impaired children in our locality were included in the study. A total of 120 children including both males and females aged 6-16 years were selected by nonprobability quota sampling method and were divided into three groups [Table 1]. Children who are totally visual impaired by birth (legally blind) and children who are free from any other form of mental or physical handicapping conditions were included in the study. Medically compromised children, children using any chemical mode of plaque control, and children under medications that could affect the state of the gingival tissues were not included in the study.
Oral examinations were carried out in their schools on a wooden chair under artificial illumination of a headlamp using a mouth mirror and a probe. The study was carried out in four phases.
Phase 1: Documentation
A self-designed format was used to record the personal details such as name, age, gender, and level of education of the child.
Phase 2: Interaction and preliminary oral examination
Interactive sessions were conducted with the visually impaired children to understand their level of cooperation and cognition. Baseline plaque (Silness and Loe index) and gingival index (Loe and Silness) and caries status were recorded to assess the oral health status.
Phase 3: Oral health education
Toothbrush and toothpaste (Colgate-Palmolive Company, USA 0.15% w/w fluoride ion) were given to all the participants. Individually, instructions regarding maintenance of good oral hygiene and horizontal scrub technique of toothbrushing were explained to all the children of respective groups. After 1 week of intervention, reinforcing the instructions to all the groups was done.
Phase 4: Assessment of impact of oral health education intervention
Oral health status of the children was evaluated by recording plaque and gingival scores at 1, 3, and 6 months intervals.
Braille pamphlet-oral hygiene instructions and method of tooth brushing (horizontal scrub method) were converted to braille text with the help of braille teacher and were given as pamphlet to the children.
| Results|| |
The obtained data were subjected to statistical analysis using ANOVA to analyze the intra- and inter-group comparisons and Tukey post-hoc test for multiple group comparisons. For all the tests, a P value of 0.05 or less was set for statistical significance, and a value of 0.001 or less represents a highly significant relation.
On intragroup comparison of mean plaque scores at different time intervals, there was a gradual decline from baseline to 6 months in all the groups. A greater reduction in mean plaque scores was observed at 6 months interval when compared to 1 and 3 months interval [Table 2]. Similarly, the mean gingival scores at different time intervals showed a gradual decline from baseline to 6 months in all the groups. A greater reduction in mean gingival scores was observed at 6 months interval when compared to 1 and 3 months interval [Table 3].
|Table 2: Intra-group comparisons of mean plaque scores at different time intervals|
Click here to view
|Table 3: Intra-group comparisons of mean gingival scores at different time intervals|
Click here to view
A greater percentage of reduction in plaque scores was observed at 6 months interval when compared to 1 and 3 months with all the groups. Group III (combination of verbal, braille, and tactile) showed higher percentage of reduction at 6 months interval when compared to Group I and II. At 6 months interval, there was no statistically significant difference between Group I and II; however, Group III showed significant difference with Group I (P = 0.00) and II (P = 0.002) [Table 4].
|Table 4: Inter-group comparison of reductions in plaque scores at different intervals|
Click here to view
Greater percentage of reduction in gingival scores was observed at 6 months interval when compared to 1 and 3 months with all the groups. Group II (verbal and braille) showed a higher percentage of reduction at 6 months interval when compared to Group I and III. At 6 months interval, there is no statistically significant difference when Group III was compared with Group I and II; however, Group I showed significant difference with Group II (P = 0.002) [Table 5].
|Table 5: Inter-group comparison of reductions in gingival scores at different intervals|
Click here to view
| Discussion|| |
Visual impairment relates to a person's eyesight, which cannot be corrected to normal vision. Nandini assessed oral health status and hygiene practices in 150 visually impaired children, out of which 37.3% of the participants were affected by dental caries and 71.3% by gingivitis.  In this study, the higher plaque and gingival scores before motivation confirm poor oral hygiene status in visually impaired children similar to earlier studies. Hence, the prime motive of this study was to instill appropriate oral health awareness in these children.  Teaching good oral hygiene practices among visually impaired children requires a special approach with time and patience. Most of these teaching programs rely on tactile senses.
Education, in general, is one of the imperative factors responsible for behavioral change in children.  Particularly, oral health education is the key to prevent oral diseases, and it is always healthier to educate school age children because schools are the best environment to teach preventive dental health practices  and through them education can reach their families and community members as well. Various studies have investigated different types of instructions (direct/indirect) such as personal instruction, audio-visual aids, and self-educational manuals.  Instructions need to be clear and simple to understand in targeting children's personal needs and also adapts to their educational level and cognitive ability  with continuous reinforcement. 
Hence in the present study, direct instructions in the form of live tactile demonstration of tooth brushing technique and indirect instructions in the form of verbal, braille text were utilized to stimulate motivation in these children. This study showed a reduction in the mean plaque and gingival scores at all time intervals in all the groups as compared to the baseline.
The highest percentage of reduction in plaque scores was observed in Group III (verbal, braille, and tactile) because apart from verbal instructions, braille text (indirect instructions) was also included and the learned information was applied by them as tactile means. This motivated them to perform better tooth brushing and thus improving their oral hygiene. In Group II, indirect instructions (verbal and braille text) were given, and these children showed better oral hygiene practices than Group I, where both direct (tactile) and indirect (verbal) instructions were given. Children of Group I revealed that they vaguely remember the method of tooth brushing (tactile demonstration) which leads to less reduction in plaque and gingival scores. Hebbal and Ankola compared plaque scores (Silness and Loe plaque index) before and after health education in visually impaired children. Audio-tactile performance technique, a specially designed health education method, was used to educate these children, and they have shown that visually impaired children can maintain an acceptable level of oral hygiene when taught with special customized methods. 
The tooth brushing technique is an important factor for effective maintenance of oral hygiene. Various techniques such as simple scrubbing  and bass method  were recommended to children. In this study, a horizontal scrub method of brushing was emphasized, since it is a technically sound method which could be easily practiced. 
Educating the children is essential but alone will not solve the health care problems. It was demonstrated that simple incentives and reinforcement by professionals encourage visually impaired children to change their behavior and maintain good oral hygiene practices.  This study has shown that the customized, individualized teaching methods for visually impaired children are extremely beneficial. Hence, when special children are concerned, health education needs to be extended to parents and other responsible persons such as their instructors who are specially trained to teach them.
| Conclusion|| |
The findings of this study showed that combination of verbal, braille text, and tactile mode of oral health education proved to be an effective tool to instill good oral hygiene practice in visually impaired children. Oral health education combined with self-maintaining skill provides maximum benefits in oral hygiene improvement of sensory impaired children.
The authors express their gratitude to the cooperation and support rendered by the children and school authorities of Zion School for Blind-Rajahmundry, Andhra School for Blind-Narsapuram, Center for Visually Challenged Braille School-Bhimavaram and Greenfield School for blind-Kakinada.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Peter S, editor. Introduction to public health dentistry. In: Essentials of Preventive and Community Dentistry. 2 nd
ed. New Delhi: Sudhir Kumar Arya, Arya Medi Publishing House; 2003. p. 1-20.
Sandeep V, Vinay C, Madhuri V, Rao VV, Uloopi KS, Sekhar RC. Impact of visual instruction on oral hygiene status of children with hearing impairment. J Indian Soc Pedod Prev Dent 2014;32:39-43.
Raj S. Living with a disability: A perspective on disability in people living with schizophrenia. Int J Psychosoc Rehabil 2013;18:115-23.
Nowak AJ, editor. Dental care for the handicapped patient - Past, present, future. In: Dentistry for the Handicapped Patient. 1 st
ed. St. Louis, MO: C V Mosby; 1976. p. 3-20.
Kumar RV, Fareed N, Shanthi M. The effectiveness of oral health education program with and without involving self-maintainable oral hygiene skills among the visually impaired children. Int J Sci Study 2013;1:51-9.
Stiefel DJ. Dental care considerations for disabled adults. Spec Care Dentist 2002;22(3 Suppl):26S-39S.
van Palenstein Helderman WH, Munck L, Mushendwa S, van't Hof MA, Mrema FG. Effect evaluation of an oral health education programme in primary schools in Tanzania. Community Dent Oral Epidemiol 1997;25:296-300.
Lim LP, Davies WI, Yuen KW, Ma MH. Comparison of modes of oral hygiene instruction in improving gingival health. J Clin Periodontol 1996;23:693-7.
Rodrigues JA, dos Santos PA, Baseggio W, Corona SA, Palma-Dibb RG, Garcia PP. Oral hygiene indirect instruction and periodic reinforcements: Effects on index plaque in schoolchildren. J Clin Pediatr Dent 2009;34:31-4.
Leal SC, Bezerra AC, de Toledo OA. Effectiveness of teaching methods for toothbrushing in preschool children. Braz Dent J 2002;13:133-6.
Nandini NS. New insights into improving the oral health of visually impaired children. J Indian Soc Pedod Prev Dent 2003;21:142-3.
Christensen GJ. Special oral hygiene and preventive care for special needs. J Am Dent Assoc 2005;136:1141-3.
Flanders RA. Effectiveness of dental health educational programs in schools. J Am Dent Assoc 1987;114:239-42.
Lees A, Rock WP. A comparison between written, verbal, and videotape oral hygiene instruction for patients with fixed appliances. J Orthod 2000;27:323-8.
Ramseier CA, Leiggener I, Lang NP, Bagramian RA, Inglehart MR. Short-term effects of hygiene education for preschool (kindergarten) children: A clinical study. Oral Health Prev Dent 2007;5:19-24.
Zaki BA, Badt HL. The effective use of self-teaching oral hygiene. J Periodontol 1974;45:491.
Hebbal M, Ankola AV. Development of a new technique (ATP) for training visually impaired children in oral hygiene maintenance. Eur Arch Paediatr Dent 2012;13:244-7.
Sgan-Cohen HD, Adut R. Promotion of gingival and periodontal health from childhood. In: Bimstein E, Needleman HL, Karimbux N, Van Dyke JE, editors. Periodontal and Gingival Health and Disease Children, Adolescents, and Young Adults. London: Martin Dunitz; 2001. p. 138-49.
Shenoy RP, Sequeira PS. Effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12- to 13-year-old school children. Indian J Dent Res 2010;21:253-9.
Yalcinkaya SE, Atalay T. Improvement of oral health knowledge in a group of visually impaired students. Oral Health Prev Dent 2006;4:243-53.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]