Effectiveness of teaching methods for toothbrushing in preschool children.

Abstract

Three different methods of instruction and motivation were used to assess the learning process and ability of preschool children in performing toothbrushing. Forty children from a private nursery of Brasília, DF, Brazil, were divided into 2 groups according to age (3-4 years old and 5-6 years old). The following methods of instruction and reinforcement were applied: I--audiovisual; II--child as a model; III--individual instruction. Professional prophylaxis was then performed and the children remained 48 hours without any kind of oral hygiene. Plaque disclosing and plaque index were carried out and recorded. The children subsequently brushed their teeth according to each method of instruction and a new plaque index was recorded. The data were analyzed statistically using the Student t-test and the comparison of two proportions. The results showed that the children of both groups reduced plaque index and that the individual instruction method was superior (p<0.05) to the others at all ages. Children older than 5 years of age were able to learn and accomplish toothbrushing better than younger children.

Full text

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Braz Dent J 13(2) 2002
Toothbrushing in preschool children
133
Braz Dent J (2002) 13(2): 133-136
Effectiveness of Teaching Methods for
Toothbrushing in Preschool Children
Soraya Coelho LEAL1
Ana Cristina Barreto BEZERRA2
Orlando Ayrton de TOLEDO2
1Area of Morphology, Faculty of Medicine, UnB, Brasília, DF, Brazil
2Department of Dentistry, Faculty of Health Sciences, UnB, Brasília, DF, Brazil
Three different methods of instruction and motivation were used to assess the learning process and ability of preschool children in
performing toothbrushing. Forty children from a private nursery of Brasília, DF, Brazil, were divided into 2 groups according to age
(3-4 years old and 5-6 years old). The following methods of instruction and reinforcement were applied: I - audiovisual; II - child as
a model; III - individual instruction. Professional prophylaxis was then performed and the children remained 48 hours without any kind
of oral hygiene. Plaque disclosing and plaque index were carried out and recorded. The children subsequently brushed their teeth
according to each method of instruction and a new plaque index was recorded. The data were analyzed statistically using the Student
t-test and the comparison of two proportions. The results showed that the children of both groups reduced plaque index and that the
individual instruction method was superior (p<0.05) to the others at all ages. Children older than 5 years of age were able to learn and
accomplish toothbrushing better than younger children.
Key Words: children, toothbrushing, education, plaque index.
Correspondence: Dra. Soraya Coelho Leal, Área de Morfologia, Faculdade de Medicina, Universidade de Brasília, Campus Universitário Asa Norte,
70910-900 Brasília, DF, Brasil. Tel: +55-61-307-2256, +55-61-315-9148. E-mail: sorayaleal@ieg.com.br
ISSN 0103-6440
INTRODUCTION
It is known that the three basic circles from Paul-
Keys (1) display the basic etiological factors of dental
caries. One of them is undoubtedly the microorganism,
which accumulates and forms biofilm, known as dental
plaque. Although there is no scientific based evidence
correlating biofilm and dental caries, it is accepted that
plaque removal is a very advisable procedure for oral
health maintenance.
There is evidence that the mechanical control of
plaque prevents gingivitis and reduces plaque (2,5).
Thus, toothbrushing continues to be the most used and
effective method for cleaning most tooth surfaces (6).
Toothbrushing, as all habits of hygiene, is ac-
quired during the socialization process of the child (7).
When this habit is taught in early childhood, it is
naturally ingrained in the daily routine of the child, with
only positive reinforcement needed later (8-9). Tooth-
brushing can be compared with other health-related
habits that will persist throughout life without great
changes (10), e.g. excessive use of sugar.
Nevertheless, it is generally known that tooth-
brushing by children under ten years of age is ineffi-
cient (11). This difficulty can be explained by the lack
of motivation and poor manual dexterity normal to this
age (12). Effective plaque removal instruction can be
taught when the child is an active part of oral hygiene
education (8,13). Instructions should be given accord-
ing to the child’s degree of readiness for toothbrushing
and should include systematic training and reinforce-
ment. Although manual dexterity and ability are neces-
sary, intensive individual training is essential (13,14).
Children should be educated in oral self-care according
to their status of psychological development (15).
Oral hygiene instructions through educational
lectures result in highly significant improvements in
oral health (16). However, there is evidence that the
development of grammatical understanding in very
young children continues for several years. This could
explain the difficulty found in the training and practice
of oral hygiene techniques in preschool children using

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S.C. Leal et al.
only verbal instructions (17). The use of audiovisual
methods is also suggested for these children (18).
Thus, this study assessed the effectiveness of 3
teaching methods for toothbrusing in preschool chil-
dren: audiovisual, child as a model and individual
instruction.
MATERIAL AND METHODS
The present study was developed in a private
nursery school in Brasília, DF, Brazil by only one
dentist. After the parents or legal guardian of the child
signed an informed consent, forty children were se-
lected as follows: age between 3-6 years, completed
primary dentition, dmfs equal to zero, and only slight to
mild gingivitis. The children were divided into 2 groups
according to age: group 1 (G1): 20 subjects – 10 chil-
dren of 3 years of age and 10 children of 4 years of age;
group 2 (G2): 20 subjects – 10 children of 5 years of age
and 10 children of 6 years of age.
Three methods of oral hygiene instruction and
reinforcement were applied separately for G1 and G2.
Method I – audiovisual: models and slide projection
with subjects and motivation appropriate for each age
group. Method II – child as a model: the dentist demon-
strated toothbrushing technique using a child as a model.
Method III – individual instruction: each child received
individual instruction.
Two toothbrushes and toothpaste of the same
brand were given to all children that participated in this
study. One of the toothbrushes remained with the den-
tist and the other one with the child. The toothbrushing
technique applied for all teeth and surfaces included
only back-and-forth movements. Immediately after the
application of the Methods I, II, and III, the following
procedures were performed: a) plaque disclosing and
professional prophylaxis using a toothbrush and tooth-
paste in order to remove all plaque; b) the person
responsible for the child was asked to not brush the
child’s teeth for 48 h for plaque accumulation; c) after
48 h, each child brushed his or her teeth according to the
instructions received before. Plaque disclosing was
carried out before and after brushing for plaque index
comparison. Scores were 0 for no plaque, 1 for thin
plaque and 2 for thick plaque.
The data were statistically analyzed utilizing the
Student t-test and the comparison of two proportions.
RESULTS
The total plaque index decreased in both groups
after the application of the three methods of instruction
and reinforcement. However, G2 had greater plaque
reduction than G1 for all methods (p<0.05) (Figure 1).
Analyzing the instruction and reinforcement
methods separately, when Method I was applied there
was no statistical difference between G1 and G2 plaque
index (p>0.05) (Figure 2). After Method II was applied,
G2 showed a significantly greater (p<0.05) percentage
of zero plaque (40.4%) compared to G1 (31.7%) (Fig-
ure 3). Individual instruction (Method III) showed the
greatest percentage of plaque index scores equal to zero
for G2 (45.8%) (Figure 4). On the other hand, the
children of G1 maintained similar values of plaque
index reduction to score zero for all three methods.
We conclude that the individual method showed
the greatest difference between G1 and G2, followed by
the audiovisual and the child as a model (Figure 1). All
Figure 1. Mean of plaque index for G1 and G2 before and after
the application of the three methods of oral hygiene and
reinforcement.
Figure 2. Frequency of plaque index for G1 and G2 before and
after the application of the audiovisual method (I).
0%
20%
40%
60%
80%
100%
Frequency (%)
012
Plaque index
G1 BeforeG1 After G2 Before G2 After
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Mean of plaque index
G1 Before G1 After G2 Before G2 After
VisualModel Individual

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Braz Dent J 13(2) 2002
Toothbrushing in preschool children
135
methods reduced the plaque index; however, the G2 (5-
6 years old) children had better performance than G1
(3-4 years old) children.
DISCUSSION
The results showed a significant relation be-
tween the methods of oral hygiene instruction and
reinforcement and the plaque index. These findings
confirm earlier studies (5,8) that suggest that instruc-
tion and supervision are important to establishing ef-
fective toothbrushing habits in children.
Williford et al. (16) reported that educational
lectures result in highly significant improvements in
oral health when applied in adolescents. However, this
method is believed to be efficient only in children over
five years of age. According to Simmons et al. (17),
most children between 2 and 4 years of age are not able
to understand the use of prepositions such as “on top
of”, “inside”, “behind”, etc. Thus, the difficulty found
in teaching toothbrushing skills to these children using
just words. Therefore, other methods, such as audiovi-
sual should be indicated for preschool children (18).
The data obtained in this study showed that, after
the application of the three methods of oral hygiene
instruction and reinforcement, the children of both
groups reduced plaque scores. However, the children
of G2 (between 5 and 6 years) reached significantly
more plaque scores equal to zero than the children of
G1 (3 and 4 years of age). Unkel et al. (11) suggest that
chronological age is a reasonable predictor of tooth-
brushing ability and that manual toothbrushing skills
are acquired after approximately four to five years.
Ogasawara et al. (14) affirm that it is possible to give
effective guidance in toothbrushing to preschool chil-
dren as long as the instructions are adapted to their age.
In the present study, the performance of pre-
school children in brushing their teeth was improved by
motivation obtained when the three methods of oral
hygiene were applied. Daly et al. (3) and Candelária et
al. (13) reported that motivation, as demonstrated in
this study, is one of the most important factors in
ensuring optimal plaque control. Stutcliffe et al. (9)
concluded that oral hygiene instruction programs have
potential value as a means of introducing young chil-
dren to future dental procedures in as pleasant a way as
possible.
We conclude that it is necessary to find which
method of oral hygiene instruction is more adequate for
each child considering age. The results showed that the
most effective method of oral hygiene instruction and
reinforcement was individual instruction independent
of the age of the child. This information is useful
because this method is both inexpensive and easily
taught.
RESUMO
Leal SC, Bezerra ACB, de Toledo OA. Avaliação da eficácia do
ensinamento de métodos de escovação dentária em crianças pré-
escolares. Braz Dent J 2002;13(2):133-136.
Com o objetivo de avaliar a capacidade de aprendizagem de
crianças pré-escolares quanto às técnicas de escovação, foram
utilizados três diferentes métodos de instrução e reforço, em uma
creche de Brasília, DF. Quarenta crianças foram divididas por
faixa etária em dois grupos de 3 e 4 anos de idade e 5 e 6 anos de
idade, respectivamente. Foram aplicados os seguintes métodos
de instrução e reforço: I – audiovisual, II – criança como modelo,
III – instrução individual. Para a avaliação da eficácia dos
Figure 3. Frequency of plaque index for G1 and G2 before and
after the application of the child as a model method (II).
Figure 4. Frequency of plaque index for G1 and G2 before and
after the application of the individual instruction method (III).
0%
20%
40%
60%
80%
100%
Frequency (%)
012
Plaque index
G1 BeforeG1 AfterG2 Before G2 After
0%
20%
40%
60%
80%
100%
Frequency (%)
012
Plaque Index
G1 BeforeG1 After G2 BeforeG2 After

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S.C. Leal et al.
métodos, após a aplicação de cada um deles foi realizada profilaxia
profissional e aguardou-se 48 horas sem que qualquer
procedimento de higienização fosse efetuado. Foram realizados
evidenciação de placa e o registro do índice de placa. As crianças
fizeram a escovação de acordo com o que aprenderam através do
método de instrução aplicado anteriormente e feito novo registro
do índice de placa. Os dados foram analisados estatisticamente e
mostraram que após a aplicação de todos os métodos houve
redução do índice de placa para os dois grupos. Quando os
métodos foram comparados entre si, o método de instrução
individual foi o que apresentou melhores resultados. Outra
conclusão foi de que as crianças de 5 e 6 anos apresentaram maior
capacidade de desempenho e aprendizagem que as crianças de 3
e 4 anos de idade.
Unitermos: crianças, escovação, educação, índice de placa.
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Accepted April 1, 2002