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Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 180-184  

Effectiveness of instructed tooth brushing on plaque and oral hygiene among the visually impaired children from a residential blind school in Pune – An interventional study

1 Department of Public Health Dentistry, Dr. DY Patil Vidyapeeth, Dr. DY Patil Dental College, Pune, Maharashtra, India
2 Department of Research, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission09-Jan-2020
Date of Decision03-Nov-2020
Date of Acceptance20-Nov-2020
Date of Web Publication3-Mar-2021

Correspondence Address:
Pradnya V Kakodkar
Dr. DY Patil Vidyapeeth, Pimpri, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_9_20

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Aim: The study was undertaken to evaluate the effect of instructed tooth brushing on plaque and oral hygiene among the visually impaired children from a residential blind school in Pune. Materials and Methods: An interventional study was conducted for 30 days at a residential Blind School for boys. Twenty-four blind children were recruited for the study. Baseline data were recorded using the modified patient hygiene performance (PHP) index and oral hygiene index-simplified (OHIS). Oral prophylaxis was undertaken. Oral health instruction pamphlet in Braille script was given to them. Supervised tooth brushing twice daily as per the musical audio instructions was performed for 30 days. Postintervention, the indices scores were recorded again. Paired t-test was used for comparison of pre and postintervention scores. Results: The modified PHP score pre and postintervention were 4.19 ± 0.54 and 1.81 ± 0.87, respectively, and the difference was statistically significant. The OHIS scores pre and postintervention were 3.31 ± 0.88 and 1.04 ± 0.54 and were also statistically significant. Conclusion: The present study revealed that the instructed tooth brushing program, along with oral prophylaxis and oral hygiene instructions in Braille for the visually impaired children for maintaining their oral hygiene is an effective method.

Keywords: Child, dental plaque, tooth brushing, visually impaired

How to cite this article:
Dagar DS, Kakodkar PV, Shetiya SH. Effectiveness of instructed tooth brushing on plaque and oral hygiene among the visually impaired children from a residential blind school in Pune – An interventional study. Med J DY Patil Vidyapeeth 2021;14:180-4

How to cite this URL:
Dagar DS, Kakodkar PV, Shetiya SH. Effectiveness of instructed tooth brushing on plaque and oral hygiene among the visually impaired children from a residential blind school in Pune – An interventional study. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Apr 12];14:180-4. Available from: https://www.mjdrdypv.org/text.asp?2021/14/2/180/310719

  Introduction Top

Poor oral health has an impact on the social and physical appearance of an individual. Maintaining good oral hygiene depends on the ability of an individual, which can become a difficult task in differently-abled people. The blind people may struggle to carry out their daily tasks with no exception to tooth brushing. In a study conducted among handicapped children in the UK, which showed that children who are handicapped or differently abled have low oral hygiene knowledge and also have poor oral hygiene.[1] The WHO estimates that 253 million people are living with visual impairment worldwide[2] The National program for Control of Blindness and Visual Impairment gives the statistics of almost 6.6 million people who are affected either by blindness or by other eye-related diseases such as cataract, of which 0.17% are children.[3]

The major problem the visually impaired people face is, finding the things on their own. Ahmad et al. and Nadini state that the majority of the blind students have poor oral hygiene and also suffer from dental caries.[4],[5] Blind people depend on the touch and sound sensation to find or to orient themselves to their surroundings.[6] Braille is a specially designed manuscript for the purpose of reading for blind people. It is a system of bumps and indentations on a surface to represent letters that can be recognized by touch. The characters are coded into small rectangular blocks, known as cells, using raised dots. Using this special method of reading, instructions can be given to blind children for oral hygiene practice.

Health education is the most acceptable approach in the prevention of disease, which can have long-term effects in visually impaired people. Oral health education may include an explanation about the oral structures, purpose of oral hygiene, and demonstration of tooth brushing and interdental cleaning using visual aids such as disclosing agents and models. However, the absence of visual stimuli makes it a challenging task for the dentist to provide oral health education to visually impaired.[7] The schools provide a conducive environment to provide health education to such population.[8] Whether or not totally visually impaired students can become productive members of society is completely dependent on the education they receive.[9]

Music has been proven as a motivating factor for any activity. Debnath et al. conducted a study and reported that the blind people and their caregivers have low knowledge of oral health maintenance.[10] Mahantesha et al. conducted a study using oral hygiene instructions in Braille and audio instructions for tooth-brushing among visually impaired children for 3 months and reported improvement in their oral health status,[11] and similar results were reported using a novel music-based tooth brushing system.[12]

As against this background, that musical audio can be beneficial for tooth brushing, an innovative “instructed tooth brushing” program was designed for the blind children. Here “instructed tooth brushing” refers to oral hygiene instructions in Braille and musical audio with tooth brushing instructions. Hence, the aim of this study was to evaluate the effect of instructed tooth brushing on plaque among visually impaired children.

  Materials and Methods Top

This interventional study was a before and after the clinical trial. It was conducted for a period of 30 days, where in the blind children had to brush their teeth twice daily following the instructions of the musical audio. Ethical clearance was obtained from the Institutional Ethics Committee (DYPDCH/51/2018). The trial was registered with the Clinical Trial Registry (Trial REF/2019/05/026026). The sample size for the study was calculated using previous literature[12] (Mean and standard deviation value 1 of gingival score: 2.15 ± 0.26.

Mean and standard deviation value 2 of gingival score: 1.84 ± 0.27) using open epi software for sample size calculation. A total sample size of 24 was calculated. The study was conducted at the Smt Patashibai Lukand residential Blind School, Bhosari, Pune, for the boys. The required number of participants was selected as per the eligibility criteria. The criteria were as follows: children with complete/partial visual impairment; parents/caregivers who were willing to give consent and children with no other impairment such as deafness, physical handicap, or systemic disease. The informed consent was obtained from the parents/caregivers and assent from the children (using braille form).

“Instructed” tooth brushing program

It consisted of two things: oral hygiene instructions in Braille[13] and musical audio with tooth brushing instructions. The musical audio was newly created for the purpose of this study . The lyrics for the audio was prepared and was further revised five times. It was pilot tested among normal children. The initial 4.25 min audio was reduced to 3.25 min for the final use. The tempo was maintained slow for the blind children to adapt to the musical audio instructions. The musical audio contained instructions for brushing starting with the labial surfaces of anterior teeth, buccal surfaces of the right side and then left, occlusal surfaces of the lower right and then left and the lingual surface of the lower teeth and occlusal surfaces of the upper right, left and the palatal surface of the upper teeth. It also had instructions for tongue cleaning and finally rinsing the mouth. The audio is available at https://www.youtube.com/watch?v=bXuYEeaehx0

Description of the study

The study was conducted in four phases. Phase 0: Baseline data collection. Phase 1: Oral prophylaxis, health education, and initiating tooth brushing with musical audio. Phase 2: Reinforcement every 1 week and Phase 3: Postintervention data collection.

Phase 0: Baseline data collection and interaction

Prior approval obtained from the principal of the school and informed consent form signed from the parent/caregiver. The intent of the study was explained, and assent was obtained from the children using the Braille script. Oral examination was performed, and their comprehension (to listen to instructions and communicate) and co-operation was assessed. The baseline plaque score was collected using for modified patient hygiene performance index (PHP),[14] and oral hygiene (debris and calculus) was assessed using oral hygiene index-simplified (OHIS).[15]

Phase 1: Oral prophylaxis, health education, and tooth brushing using musical audio

The participants identified for the study were provided with the oral prophylaxis at the baseline, after data collection. Once all the students received oral prophylaxis, they were given the oral hygiene instructions pamphlet in Braille[13] and were asked to read it twice daily. The children were familiarized with the audio. Trial for tooth brushing was taken under the supervision of the investigator. Those participants who could not brush their teeth according to the audio were taught personally by the investigator. One batch of six students each performed instructed tooth brushing. For the first 7 days, everyday morning, the instructed tooth brushing was performed under the investigator's supervision. The warden acted as the supervisor and made the children perform the tooth brushing at night and further for the rest of the duration. This tooth brushing activity continued for 30 days.

Phase 2: Reinforcement

The investigator supervised the toothbrushing once a week for the next 3 weeks, while daily supervision was done by the warden every day in the morning and night for 30 days. Reinforcement of oral hygiene instruction was done every day through the Braille pamphlet.

Phase 3: Postintervention data collection

After 30 days of the intervention, the modified PHP and OHIS scores were recorded again.

Analysis of the data

All the data were entered into the Microsoft Excel spreadsheet. Paired t-test using SPSS (version 21) was used for calculating inferential statistics. P < 0.05 was taken as statistically significant.

  Results Top

A total of 24 male blind children aged 7–17 years with a mean age of 13.3 ± 2.53 years completed the study. Eight children were completely blind and 16 were partially blind. The frequency of tooth brushing preintervention was: majority (n = 21) of the participants were brushing only once, whereas only three participants were brushing twice daily. Postintervention, all (n = 24) participants started brushing twice daily.

[Table 1] shows the preintervention and postintervention results of the modified PHP index. The modified PHP score pre and postintervention were 4.19 ± 0.54 and 1.81 ± 0.87, respectively. A statistically significant difference was noted (t = 12.10, P < 0.001). Postintervention, a mean percentage reduction of 56.41 ± 21.40% plaque was observed among the participants as compared to the baseline values.
Table 1: Pre- and postintervention comparison of modified patient hygiene performance scores

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[Table 2] shows the comparison of the OHIS scores. The mean OHIS debris score preintervention was 1.71 ± 0.64, which changed to 0.68 ± 0.44 postintervention. On comparison, a statistically significant difference was noted (t = 6.98, P < 0.001). The mean percentage of debris reduction seen was 56.99 ± 30.10%. The mean OHIS calculus score was 1.64 ± 0.65, which changed to 0.19 ± 0.32 postintervention. On comparison, a statistical significant difference was noted (t = 9.66, P < 0.001). The mean reduction of calculus formation was 85.94 ± 77.11%. The OHIS scores pre- and post-intervention were 3.31 ± 0.88 and 1.04 ± 0.54, respectively. A statistical significant difference was noted (t = 10.98, P < 0.001).
Table 2: Pre- and post-intervention comparison of OHIS scores

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Pre-intervention, as per the OHI-S overall interpretation, it was observed that only one participant had good oral hygiene, ten had fair oral hygiene and 13 had poor oral hygiene. Postintervention, there was a shift of 22 participants to a good oral hygiene category, and only two participants reported fair oral hygiene.

  Discussion Top

It is through the senses that we learn about our world; therefore, the development of a child may be severely compromised by the loss of one or more of the sensory modalities.[5] Where the normally sighted people can maintain their oral hygiene routine efficiently, it is a difficult task for blind or visually impaired people. Many studies have shown the prevalence of poor oral hygiene in blind people.[1],[16],[17] In India, it is estimated that 6.6 million people suffer from blindness comprising 0.17% of children.[3] It is very important to guide the blind people to maintain proper oral hygiene with customized health education, using aids like Braille and audio (song, story) and simply a health talk followed by reinforcement after a period of time according to their needs.[18] Educational research has shown that simple incentives and reinforcement by professionals encourage visually impaired children to change their behavior and maintain the change.[9] Teaching good oral hygiene practices to visually impaired children requires a special approach with time and patience.[5] Oral health education programs, nevertheless, are likely to be an important influence on the oral health of disabled children.[19] Literature is replete with studies using different methods (audio-tactile performance, Braille, or stories using special software)[7],[10],[11],[12],[13],[18],[20],[21],[22],[23] to improve oral hygiene and these different health education methods have shown a marked improvement in oral hygiene of visually impaired. Audio and Braille have shown to be excellent health education tools.[21]

In the present study, it was observed that only a few participants were brushing twice daily, while majority were brushing only once, which changed postintervention to twice. These results were similar to the study done by Hebbal and Ankola,[18] and Bhor et al.[20] where it was observed that there was a marked increase in brushing twice daily postintervention.

There was a marked difference in the pre and postintervention plaque scores [Table 1]. These results were similar to the results observed by Mahantesha et al.[11] and Gautam et al.[22] where they have reported the change in plaque scores of the participants.

Overall, there was a reduction in debris and calculus postintervention [Table 2]. These results were similar to the earlier studies[12],[13],[20] where touch perception and audio aids for tooth brushing was used.

To reduce apprehension during oral prophylaxis or recording of the indices, all the children were told how each instrument will be used on them and were also asked to touch it. A similar method has been followed in the earlier study.[9]

Majority studies done by other researchers have been conducted in residential schools[4],[9],[10],[11],[13],[18],[20],[21],[22] while a few others were conducted in day schools.[7],[12],[23],[24] In the residential schools, it has been observed that the environment is controlled in terms of diet, snacking in between meals, or distribution of sweets. These results have a synergetic effect on the intervention provided to the students. If the study site is a residential school, there is an additional advantage to supervise the intervention. The present study was conducted in a residential school. Their diet was standardized and was the same for all. Toothbrushing twice daily was monitored by the warden.

All the participants in the present study received oral prophylaxis at baseline after collection of required data, while it was observed that the previous studies none of them have provided oral prophylaxis preintervention. Hence, the result of the present study is the collective effect of instructional tooth brushing and oral prophylaxis.

The major problem with children is the compliance of brushing their teeth twice a day, as they consider it as a tedious work.[25] A musical audio tooth brushing system can make it interesting.

The blind school had only boys and hence can be a drawback of the study as the toothbrushing was checked only on one gender. Further, the present study was carried out for only 30 days, which can be lacunae. Assuming that they have learnt the correct method of tooth brushing, it will be important to assess the plaque scores after 3 months. Furthermore, it was a before and after the trial, which may not be the gold standard as compared to randomized controlled trial.

It is recommended that this instructed toothbrushing should be tried in different schools for visually impaired children, and long-term follow-up is needed.

  Conclusion Top

The present study revealed that the instructed tooth brushing program for visually impaired children, along with oral prophylaxis and oral instruction in Braille for maintaining their oral hygiene, is an effective method.


The authors wish to specially acknowledge the effort of Dr. Shyla Dureja (lyricist and singer) and Mr Sanjay Dureja (singer). Thanks to Dr. Anukriti Arya, Dr. Rajgauri Pol and Dr. Swati Itraj who have rendered help during the study. Thanks to Mr. Dattaray C Kamble, hostel Supritendant for giving the necessary permission.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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