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 : 2014  |  Volume : 32  |  Issue : 1  |  Page : 39--43

Impact of visual instruction on oral hygiene status of children with hearing impairment

V Sandeep, C Vinay, V Madhuri, Veerabhadra V Rao, KS Uloopi, R Chandra Sekhar 
 Department of Pediatric Dentistry, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India

Correspondence Address:
C Vinay
Department of Pediatric Dentistry, Vishnu Dental College, Bhimavaram - 534 202, Andhra Pradesh


Background: Children with hearing impairment (CHI) have poor oral health and extensive unmet treatment needs. This could be attributed to their inability to cooperate with dental treatment and lack of oral health awareness due to communication barriers. Aim: The aim of this study was to verify the impact of visual instruction on oral hygiene status of CHI. Study Design: Prospective triple blind interventional study. Materials and Methods: Oral hygiene status of 372 institutionalized CHI aged 6-16 years, divided into study (180) and control groups (192) was evaluated using Loe and Silness Gingival index and Silness and Loe Plaque index. Motivation in the form of visual instruction was done in the study group every weekend for 12 weeks and control group was followed without motivation. Oral hygiene status was re-assessed and analyzed. Statistical Analysis: Paired t-test was used to compare the scores before and after the instructions. Unpaired t-test was used for intergroup comparison between the study and control groups. Results: There was a significant mean reduction of plaque (0.37) and gingival scores (0.39) in the study group, but only marginal reduction of plaque (0.08) and gingival scores (0.1) observed in the control group. Significant gender and age variations were observed. Conclusion: Visual instruction was found to be an effective oral health education tool in CHI.

How to cite this article:
Sandeep V, Vinay C, Madhuri V, Rao VV, Uloopi K S, Sekhar R C. Impact of visual instruction on oral hygiene status of children with hearing impairment.J Indian Soc Pedod Prev Dent 2014;32:39-43

How to cite this URL:
Sandeep V, Vinay C, Madhuri V, Rao VV, Uloopi K S, Sekhar R C. Impact of visual instruction on oral hygiene status of children with hearing impairment. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2020 Oct 21 ];32:39-43
Available from:

Full Text


Good health is a fundamental right, a social goal and an essential human need. Oral health is a major determinant and an intrinsic part of general health. Children are prone to oral health problems when their oral hygiene maintenance is poor. Predominantly children who require special care are said to be under high risk in oral health perspective. [1] They often face difficulty in good oral hygiene maintenance due to their systemic illness. [1] They have poor oral health status compared with normal children due to their inaccessibility to dental care due to communication barriers. [2],[3] Children with hearing impairment (CHI) seem to be one such group lacking adequate oral health awareness to maintain their oral health owing to communication barriers. [4],[5]

Hearing impairment (HI) forms major disability affecting many children world-wide. There are 23,000-25,000 children (aged 0-15 years) who are permanently deaf or hard of hearing in UK. [6] According to National Sample Survey Organization in India, 0.4% of 1065.40 million children are hearing impaired and every child in 1000 live births suffers from HI. [7],[8] HI puts the child at risk for speech and language deficits, reduced cognitive skills, which may hinder their academic progress. [8] If the impairment is acquired early in life, it has been shown to have a devastating effect on the maturation of the child's brain and overall development. [9] All these factors contribute to their poor systemic and oral health.

Hence potential interventions to educate these children are essential regarding oral health. Various studies proved that oral hygiene instructions either direct or indirect are beneficial in normal children. [10],[11],[12],[13] However, literature is scanty regarding the type of oral hygiene instructions that best suit for CHI. Hence, the purpose of the present study was to assess the impact of visual instruction as a motivation tool on oral hygiene status of CHI.

 Materials and Methods

Ethical approval

This prospective triple blind interventional study was approved by the Institutional Ethical Review Board for research activities (IERB/VDC-113/2010). Prior written consent was obtained from the school authority and parents by explaining the intention of this motivation program.

Two schools which provide special education for CHI exists in our district, both were included in the study. By coin toss method, one school was selected as the study group where intervention was planned and other was selected as the control group. All children including both males and females aged 6-16 years (average age-10.83 years) who met the inclusion criteria were included without any sampling.

Inclusion criteria were: Children with good general health (American Society of Anesthesiologists I and II). Exclusion criteria were: Children whose parents denied their participation, children with other systemic diseases, uncooperative children unable to cope up with the examination procedure. Demographic distribution of the sample (total sample: 372), study group: 180 (Males-76; females-104; primary grade children [6-11 years]-105; secondary grade children [12-16 years]-75), control group: 192 (Males-92; females-100; primary grade children [6-11 years]-84; secondary grade children [12-16 years]-108).

Children, care takers and the examiners were unaware of the study protocol and intervention being carried out (triple blinding). Oral examinations were carried out in their schools on a wooden chair under artificial illumination of a head lamp using a mouth mirror and World Health Organization probe. Baseline gingival and plaque status were scored using Loe and Silness Gingival index [14] and Silness and Loe Plaque index. [15] The clinical examination was performed by two trained and calibrated examiners. Inter examiner variability was within the acceptable range (κ value 0.71). Scores were obtained from the gingival third of buccal and lingual surfaces on both mesial and distal sites (four measurements) and the average score was calculated. Examination of all the teeth was done and the average score of each child was calculated. Following initial examination in both the schools, oral hygiene instructions were given in the form of visual clipping in the study group, whereas no intervention was planned in the control. A tooth brush and tooth paste (Pepsodent G, Hindustan Unilever Ltd., Mumbai, India-1000 ppm of maximum available fluoride) was given to all the participants to standardize the process.

Motivation in the form of visual instruction (study group) was done by playing a 15 min video clip on a portable screen. The visual clipping was prepared by a multimedia expert under the investigators supervision. The video clip included explanation regarding the etiology and development of dental caries, periodontal diseases and tooth brushing technique (horizontal scrub method). The motivation sessions were continued at every weekend for a period of 12 weeks (12 sessions) in the study group. Control group was followed for this period without any motivation. After 12 weeks, once again gingival and plaque scores were recorded in both study and control groups and statistically analyzed with baseline scores.


The Statistical Package for Social Sciences (SPSS) (Version 16.0, SPSS Inc, Chicago) was used for data analysis Paired t-test was used to compare the scores before and after the instructions. Unpaired t-test was used for intergroup comparison. 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 in the study group there was a mean reduction of 0.37 ± 0.48 and 0.39 ± 0.57 in plaque and gingival scores respectively. In the control group, there was a mean reduction of 0.08 ± 0.36 and 0.1 ± 0.35 respectively. Intergroup comparison between study and control groups showed a significant reduction of plaque and gingival scores in the study group as shown by unpaired t-test (P < 0.001) [Table 1] and [Table 2].{Table 1}{Table 2}

On gender wise comparison, a significant reduction (P < 0.001) in gingival scores was observed in males (0.55 ± 0.54) than females (0.28 ± 0.56) in the study group. Similarly, there was more reduction in plaque scores in males (0.43 ± 0.48) than females (0.32 ± 0.47), but it was statistically insignificant (P = 0.14) [Table 3].{Table 3}

Age wise comparison in the study group showed a significant reduction in plaque scores in secondary grade children (0.52 ± 0.50) compared with primary grade children (0.26 ± 0.43). There was a reduction in gingival scores in secondary grade children, but it was statistically insignificant (P = 0.29) [Table 4].{Table 4}


In the present study, the higher plaque and gingival scores before motivation confirm poor oral hygiene status in CHI similar to earlier studies. [1],[5],[6],[7],[16] Hence, the prime motive of this study was to instill appropriate oral health awareness in these children. Education in general is one of the imperative factors responsible for behavioral change in children. [17] 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 [18] and through them education can reach their families and community members as well. [19]

Various studies have investigated different types of instructions (direct/indirect) like personal instruction, self-educational manuals and audio-visual aids [20] and reported that written instructions appear to be least effective and visual instruction have the advantage of clarity and convenience. In children instructions should be efficient in targeting their personal needs [21] and also adapted to their educational level and cognitive ability [22] with continuous reinforcement. [23] Hence in our study indirect instructions in the form of video clipping were shown on every weekend for a period of 12 weeks for better reinforcement. Video clipping has the added advantage of repetitive usage with no additional cost which can be effectively used in developing countries. Significant reduction of plaque and gingival scores were observed in the study group compared with the control group indicating positive impact of visual motivation.

The technique of tooth brushing is vital for effective maintenance of oral hygiene. Different techniques like simple scrubbing, [24] bass method [25] was recommended to children. In our study, horizontal scrub method of brushing the teeth was emphasized since it is technically sound method that could be easily practiced. [24]

Literature review suggests that males had poorer oral hygiene and periodontal status compared to their female counterparts. [26] Females seems to be more mature and health concerned compared to males. [27] Their plaque control record is good compared to males. [22] In contrast, there was a considerable reduction of plaque and gingival scores in males compared to females in our study.

Disparity in the maintenance of oral hygiene between older and younger age group children do exist. [28] Chronological age is a reasonable predictor of tooth brushing ability and manual tooth brushing skills are acquired better after 4-5 years of age. [28] In our study, there was a significant plaque reduction in secondary grade children (12-16 years) compared with primary grade children (6-11 years) indicating better performance in older age group children compared with younger ones. The increased cognitive ability and the manner of learning and initiation in older age groups might have influenced the better outcome.

Health education is essential, but will not solve the problem alone. Where special children are concerned, educational and motivational process should be extended to their parents, caregivers and instructors. Customization of treatment protocol is an essential requisite when special children are dealt with. Continuous motivation and reinforcement in the form of visual instruction is beneficial to achieve good oral hygiene levels in CHI.


Primarily this study proves that visual instruction is an effective tool to instill good oral hygiene practice in CHI. Findings of this study also suggest that gender and age variations do exist in oral hygiene performance. Further, different modes of motivation could be evaluated to deliver effective oral health education to groups such as the deaf, blind and mentally challenged children.


The cooperation rendered by the school authorities of Sri Venkateshwara School for deaf and Parivarthan special school for hearing impaired is deeply appreciated by the authors.


1Brown JP, Schodel DR. A review of controlled surveys of dental disease in handicapped persons. ASDC J Dent Child 1976;43:313-20.
2Nowak AJ. Dental care for the handicapped patient - Past, present, future. In: Nowak AJ, editor. Dentistry for the Handicapped Patient. 1 st ed. St. Louis, MO: CV Mosby; 1976. p. 3-20.
3Nahar SG, Hossain MA, Howlader MB, Ahmed A. Oral health status of disabled children. Bangladesh Med Res Counc Bull 2010;36:61-3.
4Stiefel DJ. Dental care considerations for disabled adults. Spec Care Dentist 2002;22:26S-39.
5Alsmark SS, García J, Martínez MR, López NE. How to improve communication with deaf children in the dental clinic. Med Oral Patol Oral Cir Bucal 2007;12:E576-81.
6Champion J, Holt R. Dental care for children and young people who have a hearing impairment. Br Dent J 2000;189:155-9.
7Jain M, Mathur A, Kumar S, Dagli RJ, Duraiswamy P, Kulkarni S. Dentition status and treatment needs among children with impaired hearing attending a special school for the deaf and mute in Udaipur, India. J Oral Sci 2008;50:161-5.
8Joint Committee on Infant Hearing, American Academy of Audiology, American Academy of Pediatrics, American Speech-Language-Hearing Association, Directors of Speech and Hearing Programs in State Health and Welfare Agencies. Year 2000 position statement: Principles and guidelines for early hearing detection and intervention programs. Joint Committee on Infant Hearing, American Academy of Audiology, American Academy of Pediatrics, American Speech-Language-Hearing Association, and Directors of Speech and Hearing Programs in State Health and Welfare Agencies. Pediatrics 2000;106:798-817.
9Davis A, Hind S. The impact of hearing impairment: A global health problem. Int J Pediatr Otorhinolaryngol 1999;49 Suppl 1:S51-4.
10van 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.
11Lim 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.
12Rodrigues 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.
13Leal SC, Bezerra AC, de Toledo OA. Effectiveness of teaching methods for toothbrushing in preschool children. Braz Dent J 2002;13:133-6.
14Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.
15Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.
16Kumar S, Dagli RJ, Mathur A, Jain M, Duraiswamy P, Kulkarni S. Oral hygiene status in relation to sociodemographic factors of children and adults who are hearing impaired, attending a special school. Spec Care Dentist 2008;28:258-64.
17Christensen GJ. Special oral hygiene and preventive care for special needs. J Am Dent Assoc 2005;136:1141-3.
18Flanders RA. Effectiveness of dental health educational programs in schools. J Am Dent Assoc 1987;114:239-42.
19World Health Organization. Oral Health Promotion through Schools. WHO Information Series on School Health. Document 8. Geneva: WHO; 2003.
20Lees A, Rock WP. A comparison between written, verbal, and videotape oral hygiene instruction for patients with fixed appliances. J Orthod 2000;27:323-8.
21Axelsson P. Mechanical plaque control. In: Lang N, Karring T, editors Proceedings of the 1 st European Workshop on Periodontics. London: Quintessence; 1994. p. 219-43.
22Ramseier 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.
23Zaki BA, Badt HL. The effective use of self teaching oral hygiene. J Periodontol 1974;45:491.
24Sgan-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.
25Shenoy 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.
26Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents. J Indian Soc Pedod Prev Dent 2009;27:151-7.
27Ferrazzano GF, Cantile T, Sangianantoni G, Ingenito A. Effectiveness of a motivation method on the oral hygiene of children. Eur J Paediatr Dent 2008;9:183-7.
28Unkel JH, Fenton SJ, Hobbs G Jr, Frere CL. Toothbrushing ability is related to age in children. ASDC J Dent Child 1995;62:346-8.