Oral Hygiene Instruction and Reinforcements

Oral Hygiene Indirect Instruction and Periodic Reinforcements:

Effects on Index Plaque in Schoolchildren
Jonas Almeida Rodrigues* / Patrícia Aleixo dos Santos** / Wagner Baseggio***/
Silmara Aparecida Milori Corona**** / Regina Guenka Palma-Dibb*****/
Patrícia Petromilli Nordi Sasso Garcia******

The aim of this study was to evaluate the effectiveness of the indirect instruction and the influence of the
periodic reinforcement on the plaque index in schoolchildren. Forty schoolchildren aged from 7 to 9 years
old were selected from a public school. After determining the initial O’Leary Plaque Index all schoolchild-
ren were submitted to a program for oral hygiene through indirect instruction –“The Smiling Robot”. The
schoolchildren were divided into 2 groups: with and without motivation reinforcement. The index plaque
exam was performed in both groups after 30, 60 and 90 days of the educational program. Comparing the
groups, the plaque index decreasing could be observed in the group with reinforcement with statistically sig-
nificant difference. For the group with reinforcement, statistically significant difference among the evalua-
tions was found. For the group without reinforcement, significant decrease in the plaque index was found
after 30 days when compared to the first, third and fourth evaluations. The indirect instruction with “The
Smiling Robot” promoted a positive initial impact on the decrease of plaque index in the schoolchildren. The
periodic reinforcements showed more suitable results and significant reduction of the plaque index in the
course of the evaluations.
Keywords: School based preventive programs, Motivation, Dental plaque, Oral hygiene.
J Clin Pediatr Dent 34(1): 31–34, 2009

D
INTRODUCTION trol of supragengival plaque is considered important for den-
ental caries and periodontal diseases are still consid- tal health, because it provides preservation of dental struc-
ered the most frequent oral ailments and may result tures and tissues.1,2
in dental loss if not properly managed. Regular con- To provide acceptable levels of dental plaque, patients
must be both educated in dental care and motivated to pro-
vide it. Teaching efficient toothbrushing techniques and cor-
rect use of dental floss would not be valid while patients
were not stimulated about the importance of these proce-
* Jonas Almeida Rodrigues, DDS, MSc, Dr. med dent, PhD,

dures for conserving the integrity of their health.3

Assistant of the Department of Restorative, Preventive and
Pediatric Dentistry, School of Dental Medicine, University of Bern,
Switzerland.
Toothbrushing as well as other habits of hygiene, is
acquired during the socialization process of the child4 and
** Patrícia Aleixo dos Santos, DDS, MSc, PhD, Substitute Professor

integrated in the daily routine with positive reinforcement.5

of the Department of Restorative Dentistry, Araraquara School of

However, when working with schoolchildren, the motiva-

Dentistry, São Paulo State University (UNESP), Brazil.
*** Wagner Baseggio, DDS, MSc , PhD student, Bauru School of
Dentistry, São Paulo University (USP), Brazil tion methods, apart from being efficient, lasting and easy to
use, must be attractive and arouse children´s attention. In
**** Silmara Aparecida Milori Corona, DDS, MSc, PhD, Prof, Professor

public health, when educational-preventive programs are

of the Department of Restorative Dentistry, Faculty of Dentistry of

applied, the indirect motivation must be stimulated in order

Ribeirão Preto, São Paulo University (USP), Brazil.

to reach a greater number of people at the same time.

***** Regina Guenka Palma-Dibb, DDS, MSc, PhD, Professor of the
Department of Restorative Dentistry, Faculty of Dentistry of
Nevertheless, after the conclusion of the proposed pro-
Ribeirão Preto, São Paulo University (USP), Brazil.

grams, oral hygiene levels returned to initial values,6,7 which

****** Patrícia Petromilli Nordi Sasso Garcia, DDS, MSc, PhD, Prof,

demonstrates the necessity of the programs to be periodic. In

Professor of the Department of Social Dentistry, Faculty of

other study, it was observed a behavioral change in patients

Dentistry of Araraquara, São Paulo State University (UNESP),
Brazil
submitted to participative methodology with periodic moti-
vation.8
Send all correspondence to: Jonas Almeida Rodrigues, Freiburgstrasse 7

Rodrigues et al 9 comparing different motivation methods

3010 Bern, Switzerland.

(direct and indirect) obtained considerable results in plaque

Phone: +41 31 635 8601

decrease when he used one indirect method for oral hygiene

E-mail: [email protected]

The Journal of Clinical Pediatric Dentistry Volume 34, Number 1/2009 31

Oral Hygiene Instruction and Reinforcements

instruction. This may be an advantage mainly in public Group I (20 schoolchildren) – “The Smiling Robot” with
health, in order to promote a decrease in plaque index, motivation reinforcement.
improve oral health and reach higher numbers of children at After initial plaque index exam and motivation the
the same time. schoolchildren were re-motivated in each return (after 30
The aim of this study was to verify the influence of one and 60 days) using the same method. The plaque index exam
indirect oral hygiene instruction method and its periodic was repeated after 30, 60 and 90 days.
reinforcement on plaque index in schoolchildren.
Group II (20 schoolchildren) – “The Smiling Robot”
Study population and methodology without motivation reinforcement (control).
This study was approved by the Research Ethics Com- These schoolchildren were initially examined and moti-
mittee of the School of Dentistry, São Paulo State University vated as the group I but they did not receive any motivation
(UNESP), Araraquara, Brazil (FAPESP grant #00/01775-6). afterwards. The plaque index exam was repeated after 30, 60
For the present study, 40 schoolchildren of both genders, and 90 days.
aged from 7 to 9 years, were selected from a public elemen- The first message, transmitted to both groups, contained
tary school of Araraquara, São Paulo State, SP, Brazil. To general information of prevention, as etiology of dental
select the school, it was taken into account the socio-eco- caries and periodontal disease, toothbrushing techniques,
nomic level (lower-middle class), so that the sample would dental floss use, diet and fluoride. The second message,
be homogeneous and show similar features. According to transmitted only to group I, contained more detailed infor-
the Research Ethics Committee, only children whose parents mation regarding dental caries, toothbrushing, diet and fluo-
had signed the consent form were included in this study. The ride. The third and last message transmitted important
patients’ parents or guardians were free to withdraw their aspects about periodontal disease and dental floss use.
children from the trial without justification at any stage and The evaluation method used in this study was the
any time of the evaluation. O’Leary Plaque Index, 27 scored before and 30, 60 and 90
After determining the initial plaque index level,10 all days after the application of the program. To disclose the
schoolchildren were submitted to an educational and moti- dental plaque, tablets were given to children whose were
vating program for oral hygiene through indirect instruction instructed to hold it in mouth for 1minute, spit it out and
(“The Smiling Robot”), employing the same message for 15
minutes.9
The proposed educational resource was a robot specially
designed to resemble a science fiction android, named “The
Smiling Robot.”9 whose movements and sounds were
remotely controlled, as shown in Figure 1.
This robot emitted previously recorded messages by
means of audio resources incorporated into it. The audio
equipment is constituted by a cassette player with power
amplifier, normally used in sound equipment of cars and
loudspeakers. This set is fed by an electric battery (12V) also
used in cars, which is recharged from a domestic electric net
(127/220V), when necessary.
The elaborated message was recorded in a cassette tape,
using the following resource: the voice of the speaker was
recorded and digitally saved in a magnetic disk by a com-
puter (Intel – Pentium 200 mHz), equipped with a multime-
dia plate, kind SoundBlaster. Using the resources of signals
processing available in the Gold Wave software, the
recorded voice was metallized, in order to simulate the voice
of the robot. Sequentially, sonorous and musical effects were
added. Once the message was recorded in the tape, we tested
the synchronism of the sounds emitted by the robot and the
movements that it performed.
The etiology and development of dental caries and peri-
odontal disease, fluoride use, appropriate feeding habits,
toothbrushing technique and dental floss use were carefully
approached. The time spent for each message was approxi-
mately 15 minutes.
One experimental group and one control group were
included. Figure 1. “The Smiling Robot.”

32 The Journal of Clinical Pediatric Dentistry Volume 34, Number 1/2009

 Oral Hygiene Instruction and Reinforcements

then, provide a mouthwash diluted in water. For the group without reinforcement (group II), signifi-
The obtained results were submitted to statistical analysis cant decrease in the plaque index (Wilcoxon p< 0.05) was
by Mann-Whitney test to verify the difference between the found 30 days after the application of the program (second
experimental groups, and Wilcoxon test to observe differ- evaluation) when compared to the first, third and fourth
ences among the evaluations. evaluations. No difference was found between the third and
fourth evaluations. Moreover, after 90 days, the plaque
RESULTS index was statistically higher than the evaluation carried out
The data distribution is shown in table 2 as well the 95% of before the application of the program.
confidence interval for both groups. Comparing the groups,
the plaque index decreasing could be observed in the group DISCUSSION
with reinforcement with statistically significant difference In dentistry, motivation and education are procedures
(Table 1, p< 0.05). employed with the aim of promoting an increase in the level
For the group with reinforcement (group I), there was sig- of knowledge of the patient and stimulating behavioral
nificant difference among the evaluations. The second, third changes – mainly those concerning oral hygiene. Some stud-
and fourth evaluations showed significant lower plaque ies point out the extreme importance of these educational-
index (Wilcoxon, p< 0.01) than the first evaluation, but there preventive programs that are applied with this intent.2,11–13
was no difference among them. In an earlier investigation, the authors observed that the
indirect method proposed may be effective, mainly concern-
ing children motivation. It is interesting to notice that “The
Table 1. Means (%) and standard deviations in the studied groups.

Smiling Robot” is an indirect motivation method and should

Significant differences are represented by different upper

be employed as an auxiliary motivation resource. The direct

case letters, considering the same column (Mann-Whitney
test, p<0.05).
instruction is the main motivation resource and should be
GROUP EVALUATIONS applied when the objective is to promote behavioral change.9
Dental practitioners know the difficulty of changing oral
Initial Second Third Fourth

hygiene behavior. If a patient has had a lifelong history of

I – with reinforcement 62.95a 42.38a 47.00a 42.71a

poor oral hygiene, it is almost impossible to change that per-

(± 28.51) (± 19.64) (± 21.42) (± 28.38)

son into someone who meticulously cleans his or her teeth.

II – without 53.86a 42.20a 55.91b 63.91b

This same difficulty is present in any behavioral change sit-

reinforcement (± 26.62) (± 14.99) (± 20.09) (± 20.81)

uation in all aspects of life. Behavioral change is affected

primarily by education, and this must be a major part of any
attempt to change oral hygiene. If patients understand the
reasons for suggested changes in oral hygiene behavior, and
the consequences of continuing poor oral hygiene condi-
tions, the potential for behavioral change is greatly
improved.14
The guiding principles found in health behavior models
provide useful methods to the oral health care providers in
promoting effective individual client behaviors. Theories
provide explanations about observable facts in a systematic
manner. Research regarding health behavior has explored
the effectiveness and applicability of various health models
in oral health behavior modification. The Health Belief
Model, Transtheoretical Model and Stages of Change, The-
ory of Reasoned Action, Self-Efficacy, Locus of Control,
and Sense of Coherence are examples of models that focus
on individuals assuming responsibility for their own health.
Understanding the strengths of each and their applicability
to health behaviors is critical for oral health care providers
who work with patients to adopt methods and modify behav-
iors that contribute to good oral health.15
The education and motivation are procedures employed
with the intent of promoting an increase in the patients’ level
of knowledge and stimulating behavioral changes, mainly
concerning oral hygiene. In this way, to obtain the expected
Table 2. Averages of plaque index values obtained in the different results the dentist must resort to appropriate methods com-
patible to the target public.9
evaluations and 95% of confidence interval for both groups. Signif-

Indirect methods for motivating oral health care, spe-

icant differences are represented by different letters (Wilcoxon test,
p<0.05).

The Journal of Clinical Pediatric Dentistry Volume 34, Number 1/2009 33

Oral Hygiene Instruction and Reinforcements

cially regarding oral hygiene, are very useful, both as one CONCLUSIONS
auxiliary motivation resource as a main motivation. When The indirect oral hygiene instruction with “The Smiling
working with the infantile population, verbally repeated Robot” showed a positive initial impact on the reduction of
instruction may be monotonous and tedious, depressing the the plaque index in the analyzed children. The group that
learning and becoming anti-motivating. The use of one received periodic motivation reinforcements showed more
attractive method arousing children´s attention should be suitable results at long term with significant reduction in the
stimulated. plaque index in the course of the evaluations.
In this study, data showed a positive correlation between
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The findings of the present work suggest that when the
educational process is continuously applied, behavioral
changes and improved oral health are easier achieved.

34 The Journal of Clinical Pediatric Dentistry Volume 34, Number 1/2009