Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2017  |  Volume : 35  |  Issue : 4  |  Page : 353--358

Visual pedagogy and probiotics for hearing impaired children: A pilot study

Amrita Sujlana1, Ruchika Goyal2, Parampreet Pannu1, Shireen Opal1, Palki Bansal1,  
1 Department of Pedodontics and Preventive Dentistry, BRS Dental College and General Hospital, Panchkula, Haryana, India
2 Department of Pedodontics and Preventive Dentistry, Desh Bhagat Dental College, Gobindgarh Dist Fatehgarh Sahib, Punjab, India

Correspondence Address:
Amrita Sujlana
House No. 149, Silver City Main, Zirakpur, Punjab


Context: Oral health care for children with special needs remains largely unmet. It is important that we should focus on preventive strategies for special children to help curtail and prevent oral diseases. Aim: This study aimed to assess the effect of visual pedagogy and probiotic mouth rinse on the periodontal health of hearing impaired children. Materials and Methodology: The study cohort consisted of twenty children with hearing impairment (HI) and 20 age-matched healthy children. The gingival index (GI), plaque index (PI), and salivary pH for all children were assessed at baseline, 15 days after oral hygiene training using visual pedagogy, 15 days after probiotic mouth rinse introduction, and at the end of the test period, i.e., 2 months after discontinuing probiotics. Statistical Analysis: Comparison of means was carried out using the Student's t-test. Intragroup parameters were assessed using the one-way ANOVA, followed by the post hoc Scheffe test. Value for statistical significance was fixed at 0.05. Results: The GI and PI scores did not improve significantly after oral hygiene training in either of the two groups. The use of probiotic mouth rinse significantly reduced GI scores (<0.01) and PI scores (<0.01) and increased salivary pH above the critical pH in both groups. Conclusion: The use of visual pedagogy coupled with probiotic mouth rinsing may improve the periodontal status of children with HI and should be explored as a preventive procedure for children with special health-care needs.

How to cite this article:
Sujlana A, Goyal R, Pannu P, Opal S, Bansal P. Visual pedagogy and probiotics for hearing impaired children: A pilot study.J Indian Soc Pedod Prev Dent 2017;35:353-358

How to cite this URL:
Sujlana A, Goyal R, Pannu P, Opal S, Bansal P. Visual pedagogy and probiotics for hearing impaired children: A pilot study. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2020 Jan 23 ];35:353-358
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“Special health-care needs (SHCNs)” of children is an inclusive term for any child who is hindered from achieving his/her full potential physically, mentally, or socially. The physical domain includes sensory disabilities, and one such infirmity which adversely affects the facets of daily life is hearing impairment (HI) or deafness. Deafness alone or in combination with speech impairment hampers a persons' ability to process linguistic information and thus impedes both cognitive and emotional growth.[1]

It has been estimated that 4 in every 1000 children in India suffer from severe-to-profound hearing loss.[2] Oral health-care needs of children with HI remain largely unmet. Studies carried out to assess the oral health status of children with HI in India have reported a higher prevalence of both dental caries and gingivitis vis-a-vis normal children,[3],[4],[5] thus highlighting a need for implementing inclusive health-care provision without discrimination. To achieve this, pediatric dentists should employ innovative means to provide optimal oral health care to all. The first and foremost domain that should be explored is preventing the onset of various oral diseases.

Preventive strategies begin with home-based oral hygiene practices such as toothbrushing and flossing. When dealing with HI children, a major impediment is communication and motivation when training them in various life skills, including oral hygiene maintenance. Visual learning strategies have been extensively employed to help these children acquire literacy skills.[6] The same may be employed when teaching oral hygiene practices.

In addition, treatment protocols today have undergone a paradigm shift from nonspecific to specific treatments. These include the technique of modifying plaque microbiology from pathological to commensal through the use of probiotics. Probiotics as defined by the World Health Organization in 2002 are “live microorganisms which when administered in adequate amount confer a health benefit on the host.”[7] They have been referred to as “correctives of the ecosystem” and adopt a wellness rather than an illness model, wherein they heal/stabilize oral disease conditions by establishing an oral health balance.[8] It is important to explore these newer avenues to help benefit children with SHCN.

Thus, the present study was planned to assess the efficacy of utilizing visual pedagogy and probiotics to help improve periodontal status of children with HI.

 Materials and Methodology

Sample selection

The study was planned as a pre-post multiple arm intervention study. Children to be included in the study were selected from government organizations located at Raipur Rani, Panchkula district (Haryana). Twenty institutionalized HI children aged 6–14 years and 20 age-matched healthy children were included in the study. Children with HI were randomly selected from a government-funded welfare center, while the healthy children were selected from a government school, located in an area with a similar social address.

Ethical clearance was obtained from the administrative bodies for both organizations. Prior to commencing with the study, a written informed consent was obtained from the wards of all children. Children were included in the study cohort if they were aged between 6 and 14 years and had no history of consuming antimicrobial drugs within the past 4 weeks. Any child utilizing an oral hygiene aid other than routine toothbrushing was excluded from the study. In addition, children suffering from a debilitating systemic illness, mental retardation, cerebral palsy, or any other SHCN were excluded from the study.

Intraoral examination

All the children were examined by a single examiner who was trained through repeated sessions of calibration under a supervisor. A Cohen's Kappa score of 0.80 was obtained showing good intra-examiner reliability.

The selected children were examined in a natural setting on the premises of the respective institutions while seated on an ordinary chair facing away from direct sunlight. The children were assessed for dental caries, gingival inflammation, and plaque accumulation using a mouth mirror and blunt WHO periodontal probe.[9] Dental caries was evaluated using the World Health Organization (WHO) recommendations for oral health surveys (2013);[10] gingival and plaque statuses were assessed using Loe and Silness gingival index (GI) (1963) and Silness and Loe plaque index (PI) (1964), respectively.[11],[12]

Assessment of salivary pH

Salivary pH was gauged using pH-measuring strips (SD Fine-Chem Ltd., Mumbai, India). To assess the pH, the strip was placed on the dorsal surface of the patients' tongue for a period of 30 s. Thereafter, the color change on the strip was noted and compared with a standardized color-coded chart provided by the manufacturer.

Data regarding the oral health status and salivary assessment were recorded at baseline.

Oral hygiene training

All children included in the study were trained to perform effective toothbrushing using the Fone's technique. Children were trained using a multimedia virtual patient learning module presented to them using an overhead projector. In addition, the children were instructed using a three-dimensional model of the human dentition and commercially available tooth brushes. For children with HI, this was done in the presence of specially trained teachers who could communicate with them.

The gingival/periodontal status and salivary pH were re-evaluated 15 days after completion of the oral hygiene training. Following this, the children were trained to use the probiotic mouth rinse.

Probiotic mouth rinse preparation and administration

A commercially available probiotic named Darolac (Aristo pharmaceuticals, India) available in individual sachets was utilized. Each sachet contains 1 g powder of 1.25 billion freeze-dried bacterial combination comprising Lactobacillus rhamnosus (LGG), Bifidobacterium longum, and Saccharomyces cerevisiae. The probiotic mouth rinse had to be freshly prepared by dispensing the contents of one sachet in 20 ml of filtered water in a measuring beaker.

Prior to administering the probiotic mouth rinse, the children were trained to rinse using 20 ml of plain filtered water for 2 days. Thereafter, the probiotic mouth rinse was prepared and administered to the children. The children were instructed to rinse with 5 ml of the solution for 1 min and then swallow the solution. This was repeated till the total content (i.e., 20 ml) of the preparation had been consumed. In case the child expectorated the solution, he/she was made to repeat the process. Mouth rinsing was carried out 1 hour after lunch for a period of 14 days.

After this period of mouth rinsing, the oral health/salivary status was re-evaluated. The probiotic rinse was then discontinued and the children were asked to continue performing tooth brushing as advised, and oral health evaluation was repeated after 2 months.

Statistical analysis

The collected data were statistically analyzed using the Statistical Package for the Social Sciences software version 17.0 (SPSS 17.0 Inc., Chicago, IL, USA). Comparison of means between groups was analyzed using the Student's t-test. Intragroup changes for the assessment of oral health parameters were performed using the one-way ANOVA, followed by the post hoc Scheffe test. Value for statistical significance was fixed at 0.05.


When comparing the mean levels of caries experience (decayed, missing, and filled teeth [dmft]/DMFT), GI/PI score, and salivary pH at baseline for the two groups, significantly higher scores for GI and PI for children with HI as compared to healthy children were observed [Table 1].{Table 1}

The intragroup variation in the GI scores, PI scores, and salivary pH over the total period of intervention was determined. In both the groups, we found a significant reduction in all the three parameters over the 90-day intervention period [Table 2] and [Table 3]. For HI group, mean GI values did not decrease significantly after the oral hygiene training (P = 0.19), but decreased significantly after introduction of the probiotic mouth rinse (P < 0.01). When re-evaluating the GI scores 2 months after discontinuing the preventive intervention, a significant change was seen when comparing the values to baseline scores (P < 0.01), but no change was seen when compared to the scores at 30th day of intervention (P = 0.31) [Table 4]. On evaluating PI values, a significant reduction was noted after introduction of the probiotic mouth rinse (30th day) throughout the intervention period. Salivary pH seemed to decrease significantly till the 30th day and thereafter increase when re-evaluating at the 90th day (P < 0.01) [Table 4].{Table 2}{Table 3}{Table 4}

For healthy children, mean GI values changed significantly after the use of probiotic mouth rinse was introduced to the children (P < 0.01). A statistically insignificant reduction in GI score was observed after the children were trained in only oral hygiene maintenance (P = 0.63). PI values seemed to progressively decrease over the intervention period, but the reduction was not significant at 2-month re-evaluation after discontinuing the probiotic mouth rinse (P = 0.31). When assessing the change in salivary pH, a continuous increase was noted up to the 30th day (P < 0.01) and a statistically significant decrease was observed when re-evaluating at the end of the test period (P < 0.01) [Table 4].

When comparing the mean values for oral health parameters between the two groups, we found that both PI and GI values were significantly higher for children with HI after oral hygiene training (t stat = 8.02, P < 0.01 for GI; t stat = 10.18, P < 0.01 for PI). The PI score remained high for the children with HI at the 30th day of the test period (P < 0.01). At the end of the test period, we found that values for all oral health parameters, namely, GI, PI, and salivary pH became comparable in the two groups [Table 5].{Table 5}


According to the WHO, there are 32 million children with disabling hearing loss the world over. As per the WHO, disabling hearing loss in children is referred to hearing loss >30 dB in the better hearing ear.[13] In India, the prevalence of childhood-onset deafness is estimated to stand at 2%.[2] HI commencing at a young age results in cognitive deficits including communication difficulties, delayed language development, social isolation, and stigmatization. In today's day and age, it is important that we should develop teaching strategies to create an inclusive learning environment for children with disabilities.[14] Studies have reiterated that learning through visual aids is more effective than through written instructions.[15] How HI individuals acquire knowledge in a society which primarily relies on auditory learning to navigate everyday life needs to be understood. It has been suggested that HI individuals depend greatly on visual modality to acquire knowledge.[16]

We thus decided to explore the same when teaching oral hygiene maintenance and found a marginal improvement in the gingival health of children with HI, which was comparable to healthy children. Unlike our findings, a study conducted to assess the efficiency of visual instruction to improve oral health status of children with HI showed a significant reduction in gingival and plaque scores.[17] As in our study, Doichinova and Peneva also used visual pedagogy and a motivational training program to improve the oral health status of HI children over a period of 1 year. They found that motivating children with HI is a tedious process, but once implemented, can greatly improve their oral hygiene status and reduce caries risk.[18]

Although training and motivational learning to improve oral health proves beneficial, the improvement may not be up to desired levels. In addition, children whether healthy or those with SHCN may eventually become lax when performing oral hygiene, thus employing other preventive strategies becomes crucial. Therefore, to further enhance our preventive intervention, we decided to introduce the use of probiotics.

Probiotics are known to improve oral health by creating a beneficial microbial equilibrium, a concept termed bacteriotherapy or replacement therapy.[19],[20] A probiotic intended to be used for improving oral health must possess some ideal properties. These include an ability to bind to dental surfaces, antagonize pathogenic microorganisms, modify the oral environment (e.g., pH), and modulate host humoral and cellular immunity.[21] A combination of various bacterial strains is generally used to achieve all these requirements. The combination used herein consisted of LGG, B. longum, and S. cerevisiae. LGG has been shown to adhere to dental tissues, antagonize pathogens in the oral cavity, and modulate the immunity.[22],[23] A study carried out by Näse et al. concluded that a significant reduction in dental caries was seen in children consuming milk containing LGG over a 7-month period.[24] Another study stated that using a combination of LGG and bifidobacterium administered over a short period of 3 weeks resulted in a reduction in Streptococcus mutans, as well as salivary yeast counts in a cohort of 74 individuals aged 18–35 years.[25] Furthermore, lactobacilli have shown to inhibit the growth of periodontopathogens and thus enhance periodontal health.[26] In addition, both LGG and S. cerevisiae have shown to provide relief from inflammatory bowel disease.[27],[28]

In this study, the combination of probiotic microbes resulted in a significant reduction in the amount of plaque accumulation and the resultant gingival inflammation in both groups [Table 2] and [Table 3]. Similar to our findings, a study evaluating the short-term consumption of a probiotic lozenge containing a combination of LGG and bifidobacterium resulted in a significant reduction in both GI and PI scores.[22]

We further assessed salivary pH in both groups and found it to be comparable at baseline, as well as at the end of the test period. Salivary pH at the beginning of the study was found to be below the critical pH (5.2–5.5) and continued to remain in this range after the oral hygiene training. After introduction of the probiotic mouth rinse, the salivary pH seemed to rise above the critical pH [Table 2] and [Table 3]. The salivary pH is considered to be an effective biomarker for the identification of periodontal disease.[29] Salivary pH approaching neutrality depicts a healthy periodontium and decreased cariogenicity, thus inferring that the introduction of probiotics helped improve the oral health status.

On re-evaluation, 2 months after the use of probiotic mouth rinse, there was persistence of reduced PI and GI scores [Table 2] and [Table 3]. Studies assessing installation of probiotic bacteria in the oral cavity during days following intake do not suggest that a permanent colonization occurs.[30],[31] LGG has been only temporarily detected in saliva after three times daily use of a probiotic juice over a 14-day trial period.[32] However, it has been suggested that a combination of bacterial strains may increase the possibility of installation.[33] Since we utilized a combination of probiotic microbes, it may have resulted in a prolonged bacterial colonization and thus persistence of reduced GI/PI scores. It has also been suggested that early childhood introduction of probiotics greatly enhances the chances of permanent colonization, which may prove beneficial.[20]

A major limitation of our study is that we did not carry out a microbial evaluation of plaque samples to assess a change in the bacterial ecology. An assessment of the same would further substantiate the results achieved. In addition, a randomized controlled trial should be planned to further substantiate the results. A prospective study design with a larger sample size would be needed to assess the effect of continued probiotic use on the dental caries status of the study cohort. Keeping in mind these drawbacks, we can reaffirm the use of our preventive schedule involving visual pedagogy and probiotic mouth rinses to improve the oral health of children with hearing disabilities, and recommend further research in this arena.


When caring for children with disabilities, families are vulnerable to experience stress. This stress mostly arises from increased financial pressures and physical demands of caring for a disabled child.[34],[35],[36] By adopting effective preventive programs, the stress arising from oral health-care provision may be curtailed to a large extent.

Developing a pedagogy which is inclusive of all learners helps bridge the therapeutic division for children with physical disabilities. Special care dentistry remains an important facet of pediatric dentistry. Social models today advocate that it is the society that disables an individual with impairment rather than the reverse. It is thus important that we become more empathetic and modify health-care provision to remove these societal constraints.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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